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CORK Bibliography: Emergency Medicine

85 citations. January 2008 to present

Prepared: September 2009

Archer T. Ecstasy toxicity and the cooling factor. Emergency Medicine Journal 25(8): 534-534, 2008. (6 refs.)

Backmund M; Schuetz C; Meyer K; Edlin BR; Reimer J. The risk of emergency room treatment due to overdose in injection drug users. Journal of Addictive Diseases 28(1): 68-73, 2009. (12 refs.)

This cohort study was conducted to identify risk factors for lifetime emergency room treatment due to overdose in injection drug users. Data of 1049 patients on admission for opioid detoxification were analyzed. More than every third injection drug user (34.7%) experienced emergency room treatment due to an overdose. Using multiple logistic regression not living with a significant other drug user (odds ratio [OR] = 1.78, P = .002), history of suicide attempt (OR = 3.0, P = .000), daily use of barbiturates (OR = 2.17, P = .006) and cannabis (OR = 1.89, P = .001) were independently associated with emergency room treatment, whereas shorter duration of opioid use (OR = 0.23, P = .001) was independently associated with lack of emergency room treatment. Suicidal thoughts and multiple use of central nervous system depressants should be considered in injection drug users entering the emergency room due to an overdose. Emergency rooms should be seen as important places for offering further assistance (e.g., counselling) or referral to an addiction unit to drug users.

Barrie J. Training and prescription of naloxone for personal use in overdose for opiate addicts. (editorial). Emergency Medicine Journal 25(10): 688-689, 2008. (3 refs.)

Bazargan-Hejazi S; Bazargan M; Gaines T; Jemanez M. Alcohol misuse and report of recent depressive symptoms among ED patients. American Journal of Emergency Medicine 26(5): 537-544, 2008. (46 refs.)

Objective: This study examined the magnitude of association between alcohol misuse and recent depressive symptoms. Methods: We conducted a cross-sectional study of 412 randomly selected patients at least 18 years old and seeking emergency department (ED) care. Results: Of the patients, 5 1.0% reported depressive symptoms. At-risk drinking was reported by 26.0%, and 28.2% scored positive on the Rapid Alcohol Problems Screen 4. Alcohol abuse and binge drinking were reported by 25.1% and 29%, respectively, of the patients. According to our results, at-risk drinking (odds ratio [OR] = 2.49, 95% confidence interval [CI] = 1.47-4.20, P <= .001), problem drinking (OR = 2.11, 95% CI = 1.27-3.5 1, P <= .004), drinking abuse (OR - 2.58, 95% CI = 1.51-4.40, P <.001), and binge drinking (OR = 1.89, 95% CI = 1.13-3.15, P <.001) were all related to the manifestation of depressive symptoms. Conclusions: The findings of this study yield information that could be used by ED health care practitioners and health educators to educate ED patients at risk for alcohol misuse and depression.

Bergmans Y; Spence JM; Strike C; Links PS; Ball JS; Rufo C et al. Repeat substance-using suicidal clients: How can we be helpful? Social Work in Health Care 48(4, Special Issue): 420-431, 2009. (30 refs.)

Care of clients with mental health and substance abuse problems accounts for a significant proportion of all emergency department (ED) visits. This qualitative research project sought to understand the ED experiences of men with a history of suicidal behavior and substance abuse and those of the emergency personnel who work with them. Understanding the unique positions of care providers and this client population in the ED setting can assist the social worker to advocate for this highly vulnerable group of clients and to assist an interprofessional team to develop better crisis interventions.

Bernstein E; Bernstein J. Effectiveness of alcohol screening and brief motivational intervention in the emergency department setting. (editorial). Annals of Emergency Medicine 51(6): 751-754, 2008. (24 refs.)

Binswanger IA; Takahashi TA; Bradley K; Dellit TH; Benton KL; Merrill JO. Drug users seeking emergency care for soft tissue infection at high risk for subsequent hospitalization and death. Journal of Studies on Alcohol and Drugs 69(6): 924-932, 2008. (41 refs.)

Objective: Although soft tissue infections are common among injection drug users (IDUs), little is known about the health outcomes among those who seek care for these infections. Emergency department visits are an important point-of-health-care contact for IDUs. In this prospective cohort study, we aimed to determine the hospitalization and mortality rates and factors associated with hospitalization or death among IDUs seeking emergency care for soft tissue infection. Method: Participants were English-speaking IDUs, 18 years of age and older. who sought initial care for soft tissue infection in an urban emergency department. We conducted semistructured interviews, identified hospitalizations from hospital records, and identified deaths using the National Death Index. Cox proportional hazards regression was used to investigate associations between baseline characteristics and hospitalizations or death. Results: Of 211 eligible patients, 156 (74%) participated (mean age = 42 years). There were 255 subsequent hospitalizations over a mean of 3.9 years follow-up. The hospitalization rate was 42 hospitalizations per 100 person-years (95% confidence interval [CI]: 38-48). The mortality rate was 2.0 per 100 person-years (95% CI: 1.1-3.7). Factors associated with increased risk for hospitalization or death included living on the street or in a shelter (adjusted odds ratio [AOR] = 1.75, 95% CI: 1.10-2.79), being recently incarcerated (AOR = 1.90, 95% CI: 1.05-3.44), and having insurance (AOR: 1.98, 95% CI: 1.22-3.23), Conclusions: IDUs who sought care in the emergency department for soft tissue infections were at high risk for subsequent hospitalization and death. Visits for soft tissue infections represent missed opportunities for preventive care.

Boniatti MM; Diogo LP; Almeida CL; Cardoso MD. Prevalence and record of alcoholism among emergency department patients. Clinics 64(1): 29-34, 2009. (35 refs.)

OBJECTIVES: The purpose of this study was to investigate the prevalence of alcoholism among inpatients, to identify social and demographic factors associated with this prevalence and to determine its rate of recognition by the medical team. METHODS: The study population consisted of all patients admitted to the emergency room at Hospital Sao Lucas, Porto Alegre, Brazil, between July and September of 2005. The data were collected in two steps: an interview with the patient and a review of the medical records to investigate the cases of alcoholism recorded by the medical team. The questionnaire consisted of questions concerning social and demographic data, smoking habits and Alcohol Use Disorders Identification Test. RESULTS: We interviewed 248 patients. Twenty-eight (11.3%) were identified as alcoholics. Compared to the patients with a negative Alcohol Use Disorders Identification Test value (less than 8), those with a positive Alcohol Use Disorders Identification Test were more likely to be male, illiterate and smokers. The medical records of 217 (87.5%) patients were reviewed. Only 5 (20.0%) of the 25 patients with a positive Alcohol Use Disorders Identification Test whose medical records were reviewed were identified as alcoholics by the medical team. The diagnosis made by the medical team, compared to Alcohol Use Disorders Identification Test, shows only a 20% sensitivity, 93% specificity and positive and negative predictive values of 29% and 90%, respectively. CONCLUSION: Alcoholism has been underrecognized in patients who are hospitalized, and, as such, this opportunity for possible early intervention is often lost. Key social and demographic factors could provide physicians with risk factors and, when used together with a standardized diagnostic instrument, could significantly improve the rate of identification of alcoholic patients.

Booker RJ; Smith JE; Rodger MP. Packers, pushers and stuffers-managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review. (review). Emergency Medicine Journal 26(5): 316-320, 2009. (35 refs.)

Body packing, pushing and stuffing are methods by which illicit drugs may be carried within the human body. Patients involved in these practices may present UK emergency departments with complex medical, legal and ethical considerations. This review article examines not only the evidence behind the clinical management of these patients, but also the legal powers afforded to the authorities to authorise the use of intimate searches and diagnostic imaging for forensic purposes. Serious complications from concealed drug packets are now rare, and most asymptomatic patients may be safely discharged from hospital after assessment. Emergency surgery is indicated for body packers with cocaine poisoning and for some cases of heroin poisoning. Urgent surgery is indicated for obstruction, perforation, the passage of packet fragments and failure of conservative treatment. Guidance is given for doctors who are faced with requests from the authorities to perform intimate searches and diagnostic imaging for forensic purposes.

Boudreaux ED; Baumann BM; Perry J; Marks D; Francies S; Camargo CA et al. Emergency department initiated treatments for tobacco (EDITT): A pilot study. Annals of Behavioral Medicine 36(3): 314-325, 2008. (33 refs.)

Emergency departments (EDs) have strong potential to initiate tobacco interventions with economically disadvantaged populations. We piloted three ED-initiated tobacco interventions and derived parameter estimates for future trials. The study enrolled adult patients being treated in an urban ED who were daily smokers. Exclusion criteria included severe illness or pain, isolation (for contagion), altered mental status, an insurmountable language barrier, temporary residence, and lack of telephone access. Subjects in the Bedside + Booster group received motivational counseling by a trained counselor at the bedside, up to three telephone sessions post-visit, and a self-help guide. Subjects in the Faxed Referral group had their personal contact information faxed to the hospital's tobacco dependence clinic, whereupon they received identical treatment as the Bedside + Booster group, but all sessions occurred over the telephone (i.e., no bedside counseling). The Standard Referral group received the self-help guide and a referral to the hospital's tobacco dependence clinic. We used a 2:2:1 randomization schedule to maximize our experience with the motivational interventions. Outcomes were assessed at 1 and 3 months. We enrolled 90 subjects. Of the 36 subjects assigned to the Bedside + Booster condition, 31 (87%) completed bedside counseling and at least one booster session, while 22 (61%) completed the maximum four sessions. Of the 37 subjects assigned to the Faxed Referral group, 28 (76%) completed at least one telephone session, while 19 (51%) completed the maximum four sessions. Quit attempts over the 3 months ranged from 18% (Standard Referral) to 57% (Faxed Referral). Seven-day abstinence was attained by 8% (Bedside + Booster), 14% (Faxed Referral), and 6% (Standard Referral) at 3 months. Motivational cessation counseling can be feasibly initiated during the ED encounter with minimal medical staff involvement. Adequately powered trials are needed to study ED-initiated interventions that include post-visit follow-up.

Boudreaux ED; Clark S; Camargo CA. Mood disorder screening among adult emergency department patients: a multicenter study of prevalence, associations and interest in treatment. General Hospital Psychiatry 30(1): 4-13, 2008. (33 refs.)

Objective: Planning for emergency department (ED)-initiated interventions for mood disorders requires confirmation of prevalence data, identification of predictors, and an assessment of patient interest in such interventions. Method: For two 24-h periods, consecutive patients aged 18+ years presenting to four Boston EDs were enrolled. We collected data on demographics, medical history, psychiatric history, healthcare utilization, depressive symptoms, manic symptoms and interest in hypothetical ED-initiated interventions. Patients with severe illness, altered mental status or severe emotional disturbance were excluded. Results: Of 476 screened patients, 152 (32%; 95% CI, 28-36%) screened positive for depression and 17 (4%; 95% CI, 2-6%) for mania. Depressed patients were more likely than nondepressed patients (all P<01) to have income <20,000/year (43% vs. 25%), a substance abuse history (19% vs. 5%), a chronic medical condition (67% vs. 53%), use tobacco (42% vs. 22%), have at least one ED visit in the past 6 months (76% vs. 56%) and have at least one hospitalization for substance abuse in the past 6 months (5% vs. 1%). About 50% of patients who screened positive for any mood disorder were interested in at least one ED-based intervention. Conclusion: ED patients screening positive for mood disorder symptoms are likely to have complex psychiatric, medical and social histories, which will be necessary to take into account when designing ED-initiated interventions.

Brubacher JR; Mabie A; Ngo M; Abu-Laban RB; Buchanan J; Shenton T et al. Substance-related problems in patients visiting an urban Canadian emergency department. Canadian Journal of Emergency Medicine 10(3): 198-204, 2008. (26 refs.)

Objective: For many patients with addiction and other substance problems, the emergency department (ED) is the sole provider of medical care. This study sought to determine the prevalence and characteristics of substance-related medical problems in ED patients, as defined by documentation in the medical record. We also sought to compare the ED resource use ( length of ED stay and number of revisits) of patients with and without substance problems. Methods: Trained evaluators using explicit criteria reviewed all ED charts during a 6-week period at a Canadian tertiary care teaching centre. Data was collected on demographics, documentation of problematic substance use and whether the ED visit was due to substance problems. Using a computerized database, we determined how many patients with and without substance problems had 1 or more subsequent ED visits during the 1-year period from Sept. 1, 2002, to Aug. 31, 2003. Results: Of 6064 visits made by 5194 patients, 6026 visits (99.4%) representing 5188 patients (99.9%) were captured for review. Of those visits, 674 (11.2%, 95% confidence interval [CI] 10.4%-12.0%), made by 600 patients, had documentation of problematic substance use and 521 visits (8.6%, 95% CI 7.9%-9.4%) by 469 patients were caused by substance problems. The mean age of patients with a visit due to a substance problem was 39.2 years, compared with 48.5 years for those with other visits (p < 0.001). The admission rate for substance-related visits was 25.3%, compared with 17.6% for other visits (p < 0.001). For discharged patients, the median length of the ED visit owing to substance-related problems lasted 232 minutes (IQR [interquartile range] 267 min), compared with 164 minutes (IQR 167 min) for other visits (p < 0.001). In 1 year of follow-up, 161 of 600 patients (26.8%) with a substance problem made 466 revisits (mean 0.78 revisits/patient), compared with 975 of 4588 patients (21.3%) without a substance problem who made a total of 2150 revisits (mean 0.47 revisits/patient, p < 0.001). Conclusion: Substance problems contribute significantly to ED visits, hospital admissions and duration of ED stay at a tertiary centre. It is likely that our methodology underestimates the scope of the problem and that a universal screening program would find a higher prevalence. The magnitude of this problem supports the need for an interdisciplinary identification and intervention program for ED patients with substance-related issues.

Cabanas JG; Brice JH; Woodward K. An unrecognized presentation of cocaine-associated pneumomediastinum in the prehospital setting. Prehospital Emergency Care 13(3): 384-387, 2009. (18 refs.)

Cocaine abuse is associated with a significant number of emergency medical services (EMS) calls and emergency department visits every year. The medical complications of recreational cocaine use are diverse, involving almost any body organ, and vary greatly according to the substance used and the route by which is taken. Previous reports have associated cocaine abuse with serious pulmonary complications, including barotrauma. The occurrence of barotrauma is directly related to the way cocaine is consumed. The majority may manifest clinically with subcutaneous emphysema, chest pain, and neck pain. We report a case of cocaine-induced pneumomediastinum in the prehospital environment that masqueraded as an allergic reaction. Prehospital providers should be alert for clinical manifestations suggestive of barotrauma in cocaine users.

Cherpitel C; Ye Y. Alcohol and injury in the United States general population: A risk function analysis from the 2005 National Alcohol Survey. American Journal on Addictions 18(1): 29-35, 2009. (20 refs.)

A risk function analysis of data is reported from the 2005 National Alcohol Survey on average daily volume of alcohol and frequency of consuming five or more drinks per day with reporting any injury during the preceding year, an injury that was treated, or an injury that was treated in the emergency room (ER). Data suggest the association of alcohol and injury based on ER studies is not representative of all injuries, and should be taken into account in deriving estimates of risk of injury related to alcohol and alcohol-attributable fractions based on ER studies.

Cherpitel CJ; Bernstein E; Bernstein J; Moskalewicz J; Swiatkiewicz G. Screening, Brief Intervention and Referral to Treatment (SBIRT) in a Polish emergency room: Challenges in cultural translation of SBIRT. Journal of Addictions Nursing 20(3): 127-U10, 2009. (28 refs.)

A randomized clinical controlled trial of Screening, Brief Intervention and Referral to Treatment (SBIRT) for drinking and related problems among at-risk and dependent drinkers, using nurse interventionists, was undertaken in an emergency room (ER) in Sosnowiec, Poland, the first level-one trauma center in that country. This study was the first outside of the US to test protocols developed in a 14-site collaborative SBIRT study. Because Poland has both a pattern of heavy drinking and a highly accessible specialized alcohol treatment system, it offered a key setting for cultural translation of SBIRT to the international context of a new and emerging health care system. It also offered the opportunity to test the effectiveness of SBIRT with both at-risk and dependent drinkers, and to test the feasibility of using ER nursing staff to provide the brief intervention, serving as a potential model for ongoing implementation of SBIRT in ER settings. Findings suggest that the US-based SBIRT protocols can be successfully translated to other cultures, and that nurses can be successfully trained to provide brief intervention for problem drinking in the ER setting.

Cherpitel CJ; Ye Y. Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: Data from the 2005 National Alcohol Survey. Drug and Alcohol Dependence 97(3): 226-230, 2008. (16 refs.)

Background: Substance use problems are overrepresented in probability samples of patients in primary care settings including the emergency room (ER) compared to the general population. While large proportions of those with alcohol or drug use disorders are most likely to obtain services for these problems outside the mental health or substance abuse treatment system, accounting, in part, for this overrepresentation, little is known about the association of alcohol misuse or drug use with health services utilization in the general population. Methods: The prevalence and predictive value of alcohol misuse and drub use on ER and primary care use was analyzed on 6919 respondents from the 2005 National Alcohol Survey (NAS). Results: Among those reporting an ER visit during the last year, 24% were positive for risky drinking (14+ drinks weekly for then and 7+ for females and/or 5+/4+ in a day in the last 12 months), 8% for problem drinking. 3% for alcohol dependence, and 7% for illicit drug use greater than monthly. Figures for primary care users were, respectively: 24%, 5%, 3%, and 3%. ER users were more likely to be positive for problem drinking and greater than monthly illicit drug use compared to non-ER users, while no significant differences were found in substance use for users and non-users of primary care. In logistic regression controlling for gender, age, and health insurance, problem drinkers were twice as likely as non-problem drinkers (Odds ratio, OR = 1.99) (p < 0.01), and those reporting greater than monthly drug use were almost twice as likely as those using drugs less frequently or not at all (OR = 1.92; p = 0.01) to report ER use, while those reporting alcohol dependence were 1.63 times more likely to report primary Care use (p < 0.05). Conclusion: These data support the belief that both the ER and other primary care settings are important sites for identifying those with substance use problems and for initiating a brief intervention.

Cherpitel CJ; Ye Y. Trends in alcohol- and drug-related ED and primary care visits: Data from three US national surveys (1995-2005). American Journal of Drug and Alcohol Abuse 34(5): 576-583, 2008. (17 refs.)

Objective: To evaluate trends in alcohol- and drug-related emergency department (ED) and primary care visits over the previous decade. Method: A trend analysis was conducted on substance-related health services visit data, based on self-reported drinking or drug use within six hours prior to an injury or illness event, from the 1995, 2000, and 2005 National Alcohol Surveys. Results: Although an upward trend was observed in alcohol-related ED visits from 1995 to 2005, this increase was not significant. A significant trend was found for drug-related ED visits from .6% in 1995 to 3.7% in 2005 (p < .01). In multiple logistic regression, year of survey (2000 vs. 1995) was positively predictive of drug-related ED visits, controlling for gender, age, ethnicity, and health insurance coverage; however, year of survey (2005 vs. 2000) was not significant. Conclusion: These data suggest that drug-related ED visits are continuing to increase, although the increase has not been as substantial between 2000 and 2005 as that which was observed between 1995 and 2000 and highlight the opportunity provided by the ED and primary care settings for screening and brief intervention for substance-related problems. These findings also suggest that Healthy People 2010 objectives calling for a reduction in substance-related visits may not be reached.

Chun TH; Sindelar-Manning H; Eaton CA; Lewander WJ; Spirito A. Parental factors influence teen alcohol use after an emergency department visit. Pediatric Emergency Care 24(10): 668-672, 2008. (44 refs.)

Objectives: To determine if parental factors are significant predictors of short-term adolescent drinking after an alcohol-related emergency department (ED) visit. Methods: Adolescents, 13 to 17 years, who either had evidence or reported usage of alcohol in the 6 hours before an ED visit, were eligible for this study. Alcohol use was assessed at baseline and at 3-month follow-up. Data on parental variables and parenting practices were collected at baseline. Linear regression models were created to determine the relationship between parental factors and follow-up drinking. Results: Parental alcohol use, socioeconomic status, and monitoring practices were significant predictors of adolescent alcohol use at 3-month follow-up. Conclusions: Parental factors may significantly influence subsequent adolescent drinking after an ED visit. These factors should be assessed when treating alcohol-positive teens, and parents should be advised to closely monitor their teens.

Coulton S; Perryman K; Bland M; Cassidy P; Crawford M; Deluca P et al. Screening and brief interventions for hazardous alcohol use in accident and emergency departments: A randomised controlled trial protocol. BMC Health Services Research 9(article 114), 2009. (34 refs.)

Background: There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments. Methods/design: The study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation. Discussion: This paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments.

Cremonte M; Cherpitel CJ. Performance of screening instruments for alcohol use disorders in emergency department patients in Argentina. Substance Use & Misuse 43(1): 125-138, 2008. (32 refs.)

The performance of the Alcohol Use Disorders Identification Test (AUDIT), CAGE, Brief Michigan Alcohol Screening Test (Brief MAST), Rapid Alcohol Problems Screen ( RAPS), Rapid Alcohol Problems Screen-Quantity and Frequency (RAPS4-QF), and TWEAK was evaluated against a diagnosis of alcohol dependence and harmful drinking or alcohol abuse from ICD-10 and DSM-IV criteria. Data were collected from a probability sample of 779 patients admitted to the emergency department of a public general hospital in Mar del Plata, Argentina, during the year 2001. The majority of the patients sampled were male. The age range was 18 to 89 years, with a mean value of 36 years and a median of 31 years. Almost half of the sample had an elementary school education or less. All instruments were more sensitive for alcohol dependence than for harmful drinking or abuse and more sensitive for men than for women. Findings suggest the RAPS4 and RAPS4-QF may be preferred when screening for alcohol use disorders in the emergency department in Argentina. The study's limitations are noted.

Cunningham R; Walton MA; Tripathi SP; Outman R; Murray R; Booth BM. Tracking inner city substance users from the emergency department: How many contacts does it take? Academic Emergency Medicine 15(2): 136-143, 2008. (34 refs.)

Background: Longitudinal studies of substance users report difficulty in locating and completing 12-month interviews, which may compromise study validity. Objectives: This study examined rates and predictors of contact difficulty and in-person follow-up completion among patients presenting with cocaine-related chest pain to an inner-city emergency department (ED). The authors hypothesize that less staff effort in contacting patients and lower follow-up rates would bias subsequent substance use analysis by missing those with heavier substance misuse. Methods: A total of 219 patients aged 19 to 60 years (65% males; 78% African American) with cocaine-related chest pain were interviewed in the ED and then in person at 3, 6, and 12 months. Demographics, substance use measures, and amount/type of research staff contacts (telephone, letters, home visits, and locating patient during return ED visits) were recorded. Poisson and negative binomial regression analyses were conducted to predict quantity of patient contacts for the 12-month follow-up. Results: Interview completion rates at 3, 6, and 12 months were 78, 82, and 80%, respectively. Average contact attempts to obtain each interview were 10 at 3 months (range 3-44), 8 at 6 months (1-31), and 8 at 12 months (1-49); 13% of patients required a home visit to complete the 12-month interview. Participants requiring more contact attempts by staff were younger and reported more frequent binge drinking at baseline (p < 0.05), but were less likely to meet criteria for substance abuse or dependence (p < 0.5), or to report prior mental health treatment (p < 0.05). Comparisons of parallel regressions predicting contact difficulty based on the entire sample, the low-effort group, and the difficult-to-reach group showed variation in findings. Conclusions: This study demonstrates that substantial staff effort is required to achieve adequate retention over 12 months of patients with substance misuse. Without these extensive efforts at follow-up, longitudinal analyses may be biased.

Cvetkovski S; Dietze P. The incidence and characteristics of volatile substance use related ambulance attendances in metropolitan Melbourne, Australia. Social Science & Medicine 66(3): 776-783, 2008. (15 refs.)

While there has been substantial community discussion and concern expressed about volatile substance use (VSU), there has been little research on the use and related harms of these substances compared to other drugs. In this study we address a need in existing epidemiological research on VSU harms by describing the incidence and characteristics of VSU ambulance attendances between August 1998 and May 2004 across metropolitan Melbourne relative to heroin attendances, a drug class that has received more research attention. Our analysis showed that the crude rate of VSU attendance (5.03 per 100,000 population) over the period was substantially lower than the rates of heroin "involved" and heroin "overdose" attendances (33.40 and 54.87 per 100,000, respectively). Mean age of VSU cases was 20, with users on average 8 years younger than heroin cases. Two-thirds of VSU cases were male, with the likelihood of male attendance similar to heroin involved, but significantly less likely than heroin overdose. VSU attendances were geographically more evenly distributed than heroin attendances, with VSU cases more likely to occur at public and outdoor spaces. VSU cases were also less likely to be in an altered conscious state than heroin cases, but more likely to be co-attended by police and accept transportation to hospital. We conclude that VSU and heroin related harms occurred in different cohorts across metropolitan Melbourne, and that ambulance data can supplement existing data sources to inform policy and programme development, and the monitoring of VSU harms.

de Wit M; Gennings C; Zilberberg M; Burnham EL; Moss M; Balster RL. Drug withdrawal, cocaine and sedative use disorders increase the need for mechanical ventilation in medical patients. Addiction 103(9): 1500-1508, 2008. (37 refs.)

Aims: Alcohol use disorders increase the need for mechanical ventilation (MV) in critically ill medical, surgical and trauma patients. Studies examining other drug use disorders (DUD) in trauma patients have not demonstrated heightened rates of intensive care unit (ICU) complications. Patients with asthma and concurrent cocaine or heroin use disorders have an increased need for MV. The objective of this study is to determine if the presence of DUD and drug withdrawal syndromes are associated with increased need for MV in medical patients. Design: Analysis of a national database. Setting The Nationwide Inpatient Sample, the largest all-payer in-patient database was utilized for the years 2002-2004. Participants Adult patients with one of the six common diagnoses associated with medical ICU admission were included. Intervention None. Measurements Univariate analysis and multivariate logistic regression were performed to determine if DUD and drug withdrawal were associated independently with the use of MV. Findings: A total 1 218 875 patients fulfilled one of the six diagnoses; 22 827 (1.9%) had DUD, and 102 841 (8.4%) underwent MV. Independent of the medical diagnosis, DUD was associated with an increased risk for requiring MV by univariate analysis (relative risk = 1.50, P < 0.0001). By multivariate analyses, sedative and cocaine use disorders remained associated with increased need for MV. Independent of medical diagnosis and substance, drug withdrawal was associated with increased odds of MV by both univariate and multivariate analysis (odds ratio = 2.94, P < 0.0001). Conclusions: DUD are associated with increased need for MV in medical patients. This study demonstrates the importance of screening all medical patients for DUD.

Dietze PM; Cvetkovski S; Barrat MJ; Clemens S. Patterns and incidence of gamma-hydroxybutyrate (GHB)-related ambulance attendances in Melbourne, Victoria. Medical Journal of Australia 188(12): 709-711, 2008. (23 refs.)

Objective: To examine the nature and extent of ambulance attendances involving gamma-hydroxybutyrate (GHB) and to compare these with heroin-related attendances in Melbourne, Victoria. Design: Retrospective analysis of a database of ambulance service records on attendances at non-fatal drug overdoses, March 2001 - October 2005. Participants and setting: Patients who took GHB and were attended to by an ambulance, as recorded by Metropolitan Ambulance Service (Melbourne) paramedics. Main outcome measures: Transportation to hospital by ambulance; other outcomes included number, age, sex and Glasgow Coma Score (GCS) of patients, characteristics of attendances (in public or private space, others present, police co-attendance). Results: There were 618 GHB-related ambulance attendances across the 46 months of data collection; 362 involving GHB only and 256 involving the concurrent use of GHB and other drugs. These figures compare to 3723 heroin overdoses observed during the same period. The number of GHB-related attendances increased by around 4% per month, which was a higher rate of increase than that found for heroin overdose attendances. Most patients were younger than 25 years, were attended in public spaces, and had a GCS < 10. Around 90% of patients were transported to hospital, compared with 21% of heroin overdose attendances. Conclusions: Ambulance attendance data can be used to index GHB-associated harms. The clear increases in GHB-related ambulance attendances over time highlights the need for further research on how best to respond to this emergent drug-related harm.

D'Onofrio G; Pantalon MV; Degutis LC; Fiellin DA; Busch SH; Chawarski MC et al. Brief intervention for hazardous and harmful drinkers in the emergency department. Annals of Emergency Medicine 51(6): 742-750, 2008. (31 refs.)

Study objective: To determine the efficacy of emergency practitioner-performed brief intervention for hazardous/harmful drinkers in reducing alcohol consumption and negative consequences in an emergency department (ED) setting. Methods: A randomized clinical trial (Project ED Health) was conducted in an urban ED from May 2002 to November 2003 for hazardous/harmful drinkers. Patients 18 years or older who screened above National Institute for Alcohol Abuse and Alcoholism guidelines for "low-risk" drinking or presented with an injury in the setting of alcohol ingestion were eligible. The mean number of drinks per week and binge-drinking episodes during the past 30 days were collected at 6 and 12 months; negative consequences and use of treatment services, at 12 months. A Brief Negotiation Interview performed by emergency practitioners was compared to scripted Discharge Instructions. Results: A total of 494 hazardous/harmful drinkers were studied. The 2 groups were similar with respect to baseline characteristics. In the Brief Negotiation Interview group, the mean number of drinks per week at 12 months was 3.8 less than the 13.6 reported at baseline. The Discharge Instructions group decreased 2.6 from 12.4 at baseline. Likewise, binge-drinking episodes per month decreased by 2.0 from a baseline of 6.0 in the Brief Negotiation Interview group and 1.5 from 5.4 in the Discharge Instructions group. For each outcome, the time effect was significant and the treatment effect was not. Conclusion: Among ED patients with hazardous/harmful drinking, we did not detect a difference in efficacy between emergency practitioner-performed Brief Negotiation Interview and Discharge Instructions. Further studies to test the efficacy of brief intervention in the ED are needed.

Fairbairn N; Wood E; Stoltz JA; Li K; Montaner J; Kerr T. Crystal methamphetamine use associated with non-fatal overdose among a cohort of injection drug users in Vancouver. Public Health 122(1): 70-78, 2008. (52 refs.)

Objectives: To evaluate the prevalence and correlates of non-fatal overdose among a polysubstance-using cohort of injection drug users (IDU) in Vancouver. Study design/methods: We evaluated factors associated with non-fatal overdose among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS) using univariate statistics. Self-reports of the awareness of drugs taken and drug potency, polysubstance use, and assistance received at the time of non-fatal overdose were also recorded. Results: From 1 December 2003 to 1 June 2005, 551 participants who were active injectors were followed. In total, 37 (6.7%) individuals reported experiencing a non-fatal overdose in the previous 6 months. Factors positively associated with non-fatal overdose included public injecting (odds ratio (OR) = 4.74, 95% confidence interval (CI) 2.35-9.37, P<0.001), crystal methamphetamine use (OR= 4.11) and injection (OR = 3.63), morphine injection (OR = 3.55), non-injection opiate use (OR = 3.30), frequent heroin injection (OR = 2.28) and sex trade work (OR = 2.12). Factors negatively associated with non-fatal overdose included participation in methadone maintenance therapy (OR = 0.31) and injecting atone (OR = 0.36). Sixty-two percent of individuals were unaware of drug potency, 64.9% of IDU were taking other drugs at the time of overdosing, with crack being the main drug (37.0%). Fifty-four percent were assisted by ambulance personnel, 56.8% were taken to accident and emergency or hospital, 38.1% left accident and emergency or hospital before being released, and 35.1% were given Naloxone. Conclusion: Structural interventions are needed that seek to modify the social and contextual risks for overdose, increased access to treatment programmes, and trials of novel interventions for crystal methamphetamine users.

Frazee BW; Fee C; Lynn J; Wang R; Bostrom A; Hargis C et al. Community-acquired necrotizing soft tissue infections: A review of 122 cases presenting to a single emergency department over 12 years. Journal of Emergency Medicine 34(2): 139-146, 2008. (24 refs.)

Purpose: To characterize the Emergency Department (ED) presentation of necrotizing soft tissue infections (NSTI) and identify severity markers. Procedures: Retrospective chart review of pathologically diagnosed NSTIs presenting to an urban ED from 1990-2001. Cases were identified from a surgical database, ICD-9 search and prospectively. Five Emergency Physicians (EPs) abstracted data using a standardized form. Severe NSTI was defined by any of the following: death, amputation, intensive care unit (ICU) stay > 24 h, > 300 cm(2) debrided. Severe and non-severe cases were compared using chi-square, Fisher's exact, and multivariate logistic regression testing. Findings: The 122 cases were characterized by: injection drug use, 80%; fever, 44%; systolic blood pressure (BP) < 100 mm Hg, 21%; white blood cell count (WBC) > 20 x 10(9)/L, 43%; median time to operation, 8.4 h; mortality, 16%. The managing EP suspected NSTI in 59%. A systolic BP < 100 mm Hg, BUN > 18 mg/dL, radiographic soft tissue gas, admission to a non-surgical service and clostridial species were independently associated with severe NSTI. Conclusions: Pathologically defined NSTIs have a wide spectrum of ED presentations and early diagnosis remains difficult.

French MT; Gumus G; Turner HL. The role of alcohol use in emergency department episodes. Substance Use & Misuse 43(14): 2074-2088, 2008. (34 refs.)

This study investigates the association between alcohol use and emergency-department (ED) utilization in the United States using nationally representative data from the 2001 National Health Interview Survey (N = 33,326). Estimates from our probit models indicate that among men, current drinkers are less likely to have visited the ED in the past year than former drinkers. Among women, lifetime abstainers are less likely than current drinkers to have had an ED episode. Finally, frequency of binge drinking significantly increases the likelihood of ED visits for men. The results suggest that focusing solely on problem drinking provides a limited perspective.

Gmel G; Kuendig H; Augsburger M; Schreyer N; Daeppen JB. Do objective measures of blood alcohol concentrations make more sense than self-reports in emergency department studies? Journal of Addiction Medicine 2(2): 96-102, 2008. (35 refs.)

Purpose: Concerns about self-reports have led to calls for objective measures of blood alcohol concentration (BAC). The present study compared objective measures with self-reports. Methods: BAC from breath or blood samples were obtained from 272 randomly sampled injured patients who were admitted to a Swiss emergency department (ED). Self-reports were compared a) between those providing and refusing a BAC test, and b) to estimated peak BAC (EPBAC) values based on BACs using the Wid-mark formula. Results: Those providing BACs were significantly (P < 0.05) younger, more often male, and less often reported alcohol consumption before injury, but consumed higher quantities when drinking. Eighty-eight percent of those with BAC measures gave consistent reports (positive or negative). Significantly more patients reported consumption with negative BAC measures (N = 29) than vice versa (N = 3). Duration of consumption and times between injury and BAC measurement predicted EPBAC better than did the objective BAC measure. Conclusions: There is little evidence that patients who provide objective BAC measures deliberately conceal consumption. ED studies must rely on self-reports, eg, take the time period between injury and ED admission into account. Clearly, objective measures are of clinical relevance, eg, to provide optimal treatment in the ED. However, they may be less relevant to establishing effects in an epidemiologic sense, such as estimating risk relationships. In this respect, efforts to increase the validity and reliability of self-reports should be preferred over the collection of additional objective measures.

Goldstein RA; DesLauriers C; Burda A; Johnson-Arbor K. Cocaine: History, social implications, and toxicity: A review. (review). Seminars in Diagnostic Pathology 26(1): 10-17, 2009. (44 refs.)

The amount of positive cocaine results in all urban emergency department are staggering. The ages of use are becoming more common in older age groups. Most of these patients have underlying, medical conditions, including end-stage renal disease (on hemodialysis) and heart and lung disease. Most of their visits to the emergency department are for cocaine exacerbation of underlying chronic condition, adding exponentially to health care dollars. This article describes the history and pharmacology of illicit cocaine use.

Gonzalez LM; Ferrer MEF; Llanos JPS; Pena MA; Mangado EO. Epidemiology of the drug poisionings during 1 year in the University Hospital Ramon y Cajal (Spanish). Revista Clinica Espanola 208(9): 432-436, 2008. (22 refs.)

Background: In recent years, there has been an increase of drugs poisoning cases seen in the Emergency Department. This study has aimed to evaluate the characteristics of these cases in the Ramon and Cajal Hospital in Madrid. Materials and methods. A descriptive analysis about the drug poisonings diagnosed in 2004 was performed, using a retrospective search in the database of the electronic clinical records. The studied variables were gender, age, intention, drugs, admission into the hospital and relapse. Results. There were 566 drug poisoning (47%) with a cumulative incidence of 0.1%, in which women (62.3%) were found to predominate, and the average patient age was 42.46 +/- 19.97 years (range 14-100 years). In 64.31% of the cases (566), only one kind of drug was used, benzodiazepine being the most common. This appeared at least once in 62% of the cases. Furthermore, 83% were cases of voluntary poisoning. Of the involuntary poisonings, digoxin was the most common drug with a frequency of 58.4%. A total of 28.6% of the cases were admitted into hospital, while the total number of patients who suffered a relapse in this period was 10%. Discussion. Voluntary drug intoxications are caused mostly by psychoactive drugs, likely due to a high prevalence of underlying psychiatric disease in these patients. However, unintentional intoxications are mainly found in patients under chronic treatment with drugs such as digoxin and antiepileptics. More studies should be carried out to analyze which kind of preventive actions could reduce or avoid the high number of relapses.

Greene SL; Kerr F; Braitberg G. Review article: Amphetamines and related drugs of abuse. (review). Emergency Medicine of Australasia 20(5): 391-402, 2008. (75 refs.)

Acute amphetamine toxicity is a relatively common clinical scenario facing the Australasian emergency medicine physician. Rates of use in Australasia are amongst the highest in the world. Clinical effects are a consequence of peripheral and central adrenergic stimulation producing a sympathomimetic toxidrome and a spectrum of central nervous system effects. Assessment aims to detect the myriad of possible complications related to acute amphetamine exposure and to institute interventions to limit associated morbidity and mortality. Meticulous supportive care aided by judicial use of benzodiazepines forms the cornerstone of management. Beta blockers are contraindicated in managing cardiovascular complications. Agitation and hyperthermia must be treated aggressively. Discharge of non-admitted patients from the emergency department should only occur once physiological parameters and mental state have returned to normal. All patients should receive education regarding the dangers of amphetamine use.

Hadjizacharia P; Green DJ; Plurad D; Chan LS; Inaba K; Shulman I et al. Methamphetamines in trauma: Effect on injury patterns and outcome. Journal of Trauma, Injury, Infection and Critical Care 66(3): 895-898, 2009. (10 refs.)

Background: The association of methamphetamine exposure and outcomes after trauma is not known. Methods: This study included trauma patients who underwent alcohol and illicit drug screening. Patients who had a screen positive for Methamphetamine only [METH (+)] were compared with patients with a completely negative screen for illicit drugs or alcohol [TOX (-)]. Patients with polysubstance or alcohol abuse were excluded. Logistic regression was used to determine whether METH (+) status was independently associated with injury patterns or outcomes. Associations were further evaluated by patient matching with respect to age, gender, mechanism, injured body area abbreviated injury scores, and injury severity. Results: There were 5,372 patients eligible where 526 (9.8%) were METH (+). On multivariate analysis, the METH (+) group had a significantly higher adjusted rate of intensive care unit (ICU) admission but there was no difference in mortality or complications or ICU stay. On matching, there was no difference in mortality (11.1% vs. 10.9%, p = 0.87), complication rate (5.6% vs. 4.2%, p = 0.40), and lengths of ICU and hospital stay but the METH (+) group had a higher rate of laparotomy. Conclusion: Patients exposed to Methamphetamines do not have increased mortality or complications or lengths of ICU and hospital stay. However, they are more likely to require admission to the ICU.

Hadjizacharia P; Green DJ; Plurad D; Chan LS; Law J; Inaba K; Demetriades D. Cocaine use in trauma: Effect on injuries and outcomes. Journal of Trauma, Injury, Infection and Critical Care 66(2): 491-494, 2009. (15 refs.)

Background: It has been reported that cocaine is associated with trauma patients at epidemic proportions. However, the injury patterns, complications, and mortality in cocaine test-positive trauma patients are not well known. Methods: Retrospective review of all trauma patients with toxicology screen at a Level I trauma center between January 2002 and December 2005. A total of 1,096 patients were positive for cocaine but no other substances of abuse or alcohol. Nine hundred eighty-five patients of these cocaine test-positive patients were matched to a pool of 4,846 toxicology test-negative patients admitted during the same period with respect to age (<= 18, 19-55, >55 years), gender, mechanism (blunt, penetrating), Injury Severity Score (ISS < 16, 16-25, >25), head Abbreviated Injury Score (AIS <3, >= 3), chest AIS (<3, >= 3), abdominal AIS (<3, >= 3), and extremity AIS (<3, >= 3). Matched pairs of binary outcomes were analyzed using McNemars, and continuous data were tested using the Wilcoxon signed-ranks test. Results: The two groups had similar injury patterns and there was no difference in surgical procedures between cocaine test-positive and toxicology test-negative patients. Overall, there was no difference in mortality between the cocaine and test-negative patients (6.5% vs. 6.2%; p = 0.81), or between cocaine and test-negative patients with an ISS <16 (1.4% vs. 1.5%; p = 1.00), ISS 16 to 25 (13% vs. 12%; p = 1.00), and ISS >25 (59% vs. 54%; p = 0.70). The overall incidence of complications was 4% in cocaine patients and 3.6% in test-negative patients (p = 0.72), although the incidence of pneumonia was significantly higher in the cocaine test-positive patients (p = 0.04). Conclusion: Cocaine abuse in trauma patients is concerning. This study did not show a difference in mortality or length of intensive care unit stay between cocaine positive and negative patients. However, there was a significantly higher incidence of pneumonia in cocaine positive patients. Implementation of effective prevention strategies may help reduce cocaine related victims of trauma.

Henderson S; Stacey CL; Dohan D. Social stigma and the dilemmas of providing care to substance users in a safety-net emergency department. Journal of Health Care for the Poor and Underserved 19(4): 1336-1349, 2008. (39 refs.)

There has been increasing interest in how social stigma affects health care delivery to vulnerable patients but few examples of the dilemmas that may arise for providers who care for stigma-vulnerable populations. Using qualitative data, the authors examine care delivery in a safety-net emergency department where many patients were socially disadvantaged and vulnerable to stigma because of substance use problems. Analysis of our data revealed five themes related to the dilemmas of providing care for this patient population: 1) providers valued assisting vulnerable and underserved patients; 2) providers' interactions with patients could be challenging; 3) providers did not know if substance-involved patients provided accurate medical histories; 4) providers were concerned about drug-seeking behavior; and 5) providers had to balance substance-involved patients' needs with the necessity of managing limited resources. We discuss how these themes relate to care dynamics and social stigma in the safety-net setting.

Hendrickson RG; Cloutier R; McConnell KJ. Methamphetamine-related emergency department utilization and cost. Academic Emergency Medicine 15(1): 23-31, 2008. (44 refs.)

Objective: To quantify the frequency, cost, and characteristics associated with emergency department (ED) visits that are related to methamphetamine use. Methods: This was a prospective observational study. The authors performed a training program for ED clinicians on the acute and chronic effects of methamphetamine and the signs of methamphetamine abuse. A standardized two question survey was administered to clinicians concerning the relationship between the ED visit and the patient's methamphetamine use. The survey was embedded in the patient tracking system and was required for all ED patients before disposition. Survey results were merged with administrative data on demographics, diagnosis, disposition, and charges. Univariate analyses were used to determine patient characteristics associated with methamphetamine-related ED visits. Results: The authors examined 15,038 ED visits over a 20-week period from February 2006 to June 2006. There were a total of 353 methamphetamine-related visits, for an average of 17.65 visits per week (2.4% of all visits). Hospital charges for methamphetamine-related ED visits averaged $133,181 per week, for an estimated total of $6.9 M in annual charges. Methamphetamine-related ED patients were more likely to be male (odds ratio [OR] 1.6, 95% confidence interval [CI] = 1.30 to 2.01), white (OR 1.8, 95% CI = 1.38 to 2.29), and uninsured (OR 3.2, 95% CI = 2.21 to 4.69). The top four medical conditions associated with methamphetamine-related visits were mental health (18.7%), trauma (18.4%), skin infections (11.1%), and dental diagnoses (9.6%). Conclusions: Methamphetamine abuse accounts for a modest but substantial proportion of ED utilization and hospital cost. Methamphetamine-related ED visits are most commonly related to mental illness, trauma, skin, and dental-related problems.

Hermann L; Jagoda A. Opiates and acute pulmonary oedema: Addicted to the wrong therapy. Emergency Medicine Australasia 20(5): 379-381, 2008. (12 refs.)

This note comments upon Dr Sosnowski's article 'Lack of effect of opiates in the treatment of acute cardiogenic pulmonary oedema' in this issue of Emergency Medicine Australasia not only because it helps to dispel the persistent mythology that surrounds the use of i.v. opiates in the treatment of acute pulmonary oedema (APO), but also because it points out several of the fundamental issues that plague the current management of acute decompensated heart failure,

Indig D; Copeland J; Conigrave KM. Comparing methods of detecting alcohol-related emergency department presentations. Emergency Medicine Journal 26(8): 596-600, 2009. (23 refs.)

Objectives: To assess the strengths and limitations of different methods for detecting alcohol-related emergency department (ED) presentations and to compare the characteristics of patients who present to the ED with an alcohol-related presentation with ED patients who are found to be risky drinkers by a questionnaire. Methods: Survey at two Sydney Australia ED over four weekends of 389 patients. Alcohol-related presentations were identified using a range of methods and were compared with presentations in ED patients who reported risky drinking using the alcohol use disorders identification test (AUDIT). Results: Overall, 20% of ED patients had alcohol-related presentations and 28% were identified as risky drinkers by AUDIT. Diagnostic codes detected only 7% of all alcohol-related ED presentations, compared with 34% detected by nursing triage text, 60% by medical record audits and 69% by self-report. Among risky drinkers, just over half (51%) were not attending for an alcohol-related reason, whereas among alcohol-related ED presentations, nearly a third (31%) were not identified as risky drinkers by AUDIT. Conclusions: Not all patients with an alcohol-related ED presentation usually drink at risky levels, nor do all risky drinkers present to the ED for an alcohol-related reason. The use of routinely recorded nursing triage text detects over a third of alcohol-related ED presentations with no additional burden on busy clinicians. As these data are potentially readily accessible, further research is needed to evaluate their validity for the detection of alcohol-related ED presentations.

Indig D; Copeland J; Conigrave KM; Rotenko I. Why are alcohol-related emergency department presentations under-detected? An exploratory study using nursing triage text. Drug and Alcohol Review 27(6): 584-590, 2008. (45 refs.)

Introduction and Aims. This study examined two methods of detecting alcohol-related emergency department (ED) presentations, provisional medical diagnosis and nursing triage text, and compared patient and service delivery characteristics to determine which patients are being missed from formal diagnosis in order to explore why alcohol-related ED presentations are under-detected. Design and Methods. Data were reviewed for all ED presentations from 2004 to 2006 (n=118 881) for a major teaching hospital in Sydney, Australia. Each record included two nursing triage free-text fields, which were searched for over 60 alcohol-related terms and coded for a range of issues. Adjusted odds ratios were used to compare diagnostically coded alcohol-related presentations to those detected using triage text. Results. Approximately 4.5% of ED presentations were identified as alcohol-related, with 24% of these identified through diagnostic codes and the remainder identified by triage text. Diagnostic coding was more likely if the patient arrived by ambulance [odds ratio (OR)=2.35] or showed signs of aggression (OR=1.86). Failure to code alcohol-related issues was more than three times (OR=3.23) more likely for patients with injuries. Discussion and Conclusions. Alcohol-related presentations place a high demand on ED staff and less than one-quarter have an alcohol-related diagnosis recorded by their treating doctor. In order for routine ED data to be more effective for detecting alcohol-related ED presentations, it is recommended that additional resources such as an alcohol health worker be employed in Australian hospitals. These workers can educate and support ED staff to identify more clearly and record the clinical signs of alcohol and directly provide brief interventions.

Karbakhsh M; Zandi NS. Pattern of poisoning in the elderly: An experience from Tehran. Clinical Toxicology 46(3): 211-217, 2008. (30 refs.)

Introduction. Poisoning is considered a significant health problem in the elderly. This study aimed to portray the pattern of poisoning in the elderly population of Tehran. Methods. This cross-sectional study included all patients aged 60 years and older with acute poisoning who attended the emergency department of the Loghman-Hakim hospital over a six-month period (n=299). Results. Episodes of poisoning were more common in men (70.9%) and the majority of incidents took place in the patient's own home (84.3%). Most episodes were accidental (53.2%) followed by attempted suicide (32.4%). Opioids and opiate products accounted for 54.02% of the non-pharmaceutical substances that were involved in episodes of poisoning. Overdose with opioids and opiate products, was higher in male patients than in female patients. The most frequently involved drug groups were benzodiazepines, antidepressants, and analgesics. The most common cause of accidental poisoning was overdose by drug abusers. The Poisoning Severity Score was minor in 25.4%, moderate in 52.2%, and severe in 17.1% of patients. Asymptomatic patients accounted for 5.4% of the total. Unfortunately, 11.7% of patients died. The main agents involved in the fatal cases were opioids and opiate products. Conclusion. The commonest method of accidental poisoning was overdose in opioid and opiate abusers. Attempted suicide was also very common comprising about one third of all cases. The high mortality observed in this study warrants attention to the risk factors and prognostic factors of poisoning in elderly.

Katz DA; Graber M; Birrer E; Lounsbury P; Baldwin A; Hillis SL et al. Health beliefs toward cardiovascular risk reduction in patients admitted to chest pain observation units. Academic Emergency Medicine 16(5): 379-387, 2009. (47 refs.)

Even after acute coronary syndrome (ACS) is ruled out, observational studies have suggested that many patients with nonspecific chest pain have a high burden of cardiovascular risk factors (CRFs) and are at increased long-term risk of ischemic heart disease (IHD)-related mortality. The aim of this study was to evaluate the premise that evaluation in an observation unit for symptoms of possible ACS is a "teachable moment" with regard to modification of CRFs. The authors conducted a baseline face-to-face interview and a 3-month telephone interview of 83 adult patients with at least one modifiable CRF who presented with symptoms of possible ACS to an academic medical center. Existing questionnaires were adapted to measure Health Belief Model (HBM) constructs for IHD. Stage of change and self-reported CRF-related behaviors (diet, exercise, and smoking) were assessed using previously validated measures. The paired t-test or signed rank test was used to compare baseline and 3-month measures of health behavior within the analysis sample. Of the 83 study patients, 45 and 40% reported having received clinician advice regarding diet and physical activity during the observation unit encounter, respectively; 69% of current smokers received advice to quit smoking. Patients reported lower susceptibility to IHD (13.3 vs. 14.0, p = 0.06) and greater perceived benefit of healthy lifestyles (27.5 vs. 26.4, p = 0.0003) at 3-month follow-up compared to baseline. Patients also reported greater readiness to change and improved self-reported behaviors at follow-up (vs. baseline): decreased intake of saturated fat (10.1% vs. 10.5% of total calories, p = 0.005), increased fruit and vegetable intake (4.0 servings/day vs. 3.6 servings/day, p = 0.01), and fewer cigarettes (13 vs. 18, p = 0.002). Observed changes in IHD health beliefs and CRF-related behaviors during follow-up support the idea that observation unit admission is a teachable moment. Patients with modifiable risk factors may benefit from systematic interventions to deliver CRF-related counseling during observation unit evaluation.

Kelly TM; Donovan JE; Chung T; Bukstein OG; Cornelius JR. Brief screens for detecting alcohol use disorder among 18-20 year old young adults in emergency departments: Comparing AUDIT-C, CRAFFT, RAPS4-QF, FAST, RUFT-Cut, and DSM-IV 2-Item Scale. Addictive Behaviors 34(8): 668-674, 2009. (46 refs.)

Background: This study compared six of the briefest screening instruments for detecting DSM-IV-defined Alcohol Use Disorder (AUD) among older adolescents treated in Emergency Departments (ED). Methods: The AUDIT-C, the RAPS4-QF, the FAST, the CRAFFT, the RUFT-Cut, and 2-Items from the Diagnostic and Statistical Manual IV of the American Psychiatric Association [American Psychiatric Association (1994). Diagnostic and Statistical Manual of Psychiatric Disorders, (1994) (DSM-IV). 4th ed. Washington D.C.: American Psychiatric Association] criteria for AUD (heretofore referred to as the DSM-IV 2-Item Scale) were evaluated against the criterion of a current DSM-IV diagnosis of either alcohol abuse or dependence. The instruments were administered to 181 alcohol-using older adolescents (57% males; age range 18-20 years) in an ED and compared using Receiver Operator Characteristic (ROC) analyses against the criterion of a current DSM-IV diagnosis of alcohol abuse or dependence. Results: Of these instruments, the DSM-IV 2-Item Scale performed best for identifying AUD (88% sensitivity and 90% specificity), followed by the FAST and the AUDIT-C. Conclusions: Two items from the DSM-IV criteria for AUD performed best for identifying ED-treated older adolescents with alcohol use disorders. The FAST and AUDIT-C performed well, but are longer and more difficult to score in the hectic environment of the Emergency Department.

Krug I; Treasure J; Anderluh M; Bellodi L; Cellini E; Di Bernardo M et al. Present and lifetime comorbidity of tobacco, alcohol and drug use in eating disorders: A European multicenter study. Drug and Alcohol Dependence 97(1-2): 169-179, 2008. (84 refs.)

Objectives: To assess the differences in comorbid lifetime and current substance use (tobacco, alcohol and drug use) between eating disorder (ED) patients and healthy controls in five different European countries. Method: A total of 1664 participants took part in the present study. ED cases (n=879) were referred to specialized ED units in five European countries. The ED cases were compared to a balanced control group of 785 healthy individuals. Assessment: Participants completed the Substance Use Subscale of the Cross Cultural (Environmental) Questionnaire (CCQ), a measure of lifetime tobacco, alcohol and drug use. In the control group, also the GHQ-28, the SCID-1 interview and the EAT-26 were used. Results: ED patients had higher lifetime and current tobacco and general drug use. The only non-significant result was obtained for lifetime and current alcohol use. Significant differences across ED subdiagnoses and controls also emerged, with BN and AN-BP generally presenting the highest and AN-R and controls the lowest rates. The only exception was detected for alcohol use where EDNOS demonstrated the highest values. Only a few cultural differences between countries emerged. Conclusions: With the exception of alcohol consumption, tobacco and drug use appear to be more prevalent in ED patients than healthy controls. The differential risk observed in patients with bulimic features might be related to differences in temperament or might be the result of increased sensitivity to reward.

Lee HKH; Ting SM; Lau FL. A randomised control trial comparing the efficacy of tramadol and paracetamol against ketorolac and paracetamol in the management of musculoskeletal pain in the emergency department. Hong Kong Journal of Emergency Medicine 15(1): 5-11, 2008. (8 refs.)

Background: This study aimed to compare the efficacy, acceptance and side effects of intramuscular tramadol and ketorolac in combination with oral paracetamol in the emergency setting. Materials and methods: This was a randomised, double blind controlled trial. Patients aged 18 years or above with moderate to severe musculoskeletal pain were recruited. Patients with known allergy, currently on psychiatric medication, with alcohol or opiold dependence, during pregnancy and with major systemic illness were excluded. Tramadol 100 mg or ketorolac 30 mg was given intramuscularly together with paracetamol 500 mg per oral. They were then bed rested in the observation ward for one hour. Visual analogue scale (VAS), satisfaction score, vital signs and side effects were recorded. Results: Altogether, 78 (M: 43, F: 35) subjects were recruited from June to September 2005, with equal number in each arm. The mean age was 39.9 for the tramadol group and 43.9 for the ketorolac group. Most of them suffered from back pain (66.7%). There was a significant difference in VAS improvement between the two groups (0.88; P=0.01). However, there were no significant differences in patients' satisfaction score and admission rate. The incidence of side effects was similar b, tween the two groups (tramadol 19, ketorolac 17), mainly dry mouth, and none were major. The tramadol group had more nausea. Conclusion: The analgesic effect of the tramadol and paracetamol combination is as effective as the ketorolac and paracetamol combination. Tramadol is well tolerated and relatively safe. It is also cheaper than ketorolac. Hence, we recommend tramadol and paracetamol combination for acute moderate to severe musculoskeletal pain in the emergency setting.

Leontieva L; Horn K; Helmkamp J; Furbee M; Jarrett T; Williams J. Counselors' reflections on the administration of screening and brief intervention for alcohol problems in the emergency department and 3-month follow-up outcome. Journal of Critical Care 24(2): 273-279, 2009. (30 refs.)

Objectives: The purpose of this paper was to explore how events that counselors endorsed occurring during an emergency department-based screening and brief intervention (SBI) for drinking discriminate patients who reported change in Alcohol Use Disorder Identification Test (AUDIT) domains at follow-up from those who did not. Method: Patients who scored ">5" on the AUDIT were eligible for SBI. At the end of each intervention, counselors completed the questionnaire indicating which parts of the intervention they just used. Results: Discriminant function analyses indicated that "Referral made" discriminated for alcohol intake change (Wilks' lambda = 0.993, P < .05) "Did the patient set goals during intervention?" and "Referral made" discriminated for alcohol dependency change (Wilks' lambda = 0.940 and Wilks' lambda = 0.919, P < .05, respectively). "Intention to quit" (Wilks' lambda = 0.984, P < .05) discriminated for alcohol-related harm change. Conclusions: Making referrals to addiction treatment during motivational intervention discriminated for alcohol intake and dependency change. Working on intention to quit is an important point in changing alcohol-related harm. When conducting the SBI in ED, counselors may be mindful in making appropriate referrals to address alcohol use and examine intention to quit to maximize the efficacy of the harm-reduction approach.

Linakis JG; Chun TH; Mello MJ; Baird J. Alcohol-related visits to the emergency department by injured adolescents: A national perspective. Journal of Adolescent Health 45(1): 84-90, 2009. (32 refs.)

Purpose: Alcohol use is a risk factor for injury in adolescents. Many injured adolescents require treatment in emergency departments (EDs). The present study was intended to explore this association between adolescent alcohol use and injury-related ED visits using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative probability sample of visits to EDs. Methods: This was a retrospective, cross-sectional study using data from NHAMCS for 2001 through 2004. ED visits by injured adolescents aged 13-20 years whose visits were determined by NHAMCS coders to be related to alcohol were compared with visits by those whose visits were determined not related to alcohol. Specific variables of interest included demographic and medical characteristics of visits. Results: Our analyses indicated that there were several visit-related characteristics that were associated with alcohol-related ED visits, including time of visit, type of health insurance, and geographic location of the ED. Similarly, there were a number of patient-related characteristics that were also associated with alcohol-related visits to the ED, including patient acuity and injury intentionality. Conclusions: Our findings suggest that injured adolescents are more likely to present to the ED with an alcohol-related visit during the early hours of the morning, that the injury is more likely to be assault related and of higher acuity than non-alcohol-related visits. These findings suggest the ED as a potential site for alcohol prevention interventions with younger adolescents. However, these interventions will need to take into account when such adolescents will present to the ED and will need also to recognize that factors such as violence and aggression, in addition to alcohol use, may be important issues to address in the intervention.

MacEwen C; Ward M; Buchan A. A case of cocaine-induced basilar artery thrombosis. (review). Nature. Clinical Practice Neurology 4(11): 622-626, 2008. (17 refs.)

Background: A 40-year-old man presented to an emergency department with slurred speech, diplopia and agitation several hours after cocaine use. His level of consciousness rapidly dropped in the hours following presentation. Investigation Physical examination, CT scan of the head, cerebral angiography. Diagnosis Cocaine-induced basilar artery thrombosis. Management Intra-arterial thombolysis, mechanical clot aspiration, intravenous abciximab, neurointensive care support, rehabilitation at a specialist stroke unit.

Magill M; Barnett NP; Apodaca TR; Rohsenow DJ; Monti PM. The role of marijuana use in brief motivational intervention with young adult drinkers treated in an emergency department. Journal of Studies on Alcohol and Drugs 70(3): 409-413, 2009. (22 refs.)

Objective: The aim of this research was to study marijuana use, associated risks, and response to brief motivational intervention among young adult drinkers treated in an emergency department. Method: Study participants (N = 215; ages 18-24) were in a randomized controlled trial for alcohol use that compared motivational interviewing with personalized feedback (MI) with personalized feedback only. Past-month marijuana users were compared with nonusers on demographics, readiness, self-efficacy, and behavioral risk variables. Marijuana use was examined as a potential moderator of alcohol outcomes. Whether marijuana use alone or combined marijuana and alcohol use would be reduced as a result of brief intervention for alcohol was examined at 6 and 12 months. Results: Current marijuana users were younger, were more likely to be white, and reported more alcohol use, other illicit drug use, and more alcohol-related consequences than nonmarijuana users. Marijuana use at baseline did not moderate response to brief alcohol treatment. Marijuana use declined from baseline to 6 months for both treatment groups, but only MI participants continued to reduce their use of marijuana from 6- to 12-month follow-up. Reductions in number of days of use of marijuana with alcohol appeared to be primarily a function of decreased alcohol use. Conclusions: Young adult drinkers reporting current marijuana use are at generally higher risk but responded to brief alcohol treatment by reducing alcohol and marijuana use.

Marc B. Current clinical aspects of drug-facilitated sexual assaults in sexually abused victims examined in a forensic emergency unit. Therapeutic Drug Monitoring 30(2): 218-224, 2008. (18 refs.)

Sexual assault is defined as any undesired physical contact of a sexual nature perpetrated against another person and is a prevalent problem presenting at emergency departments, emergency forensic medicine units, and rape crisis centres worldwide. Drug-facilitated sexual assault (DFSA) is a complex problem that is encountered with increasing frequency. But this problem is often underrepresented because most DFSAs are not reported by the frightened victims or are diagnosed as an acute drug or alcohol intoxication, thereby bypassing sexual abuse diagnosis and appropriate care. Proper care must be taken to ensure the chain of custody. Emergency physicians need to be aware of the phenomenon and work together with reference emergency forensic medicine units and rape crisis centres, which are capable of taking care of the male and female victims of sexual abuse. If no attention is given to the risk of DFSA, then toxicological samples (urine, blood, hair) and other biologic evidence may remain unidentified and semen, vaginal secretions, and vaginal epithelial cells cannot be genetically typed by a crime laboratory. This article reports the main clinical aspects of DFSA encountered in emergency departments at the beginning of the 21st century and the experience of an emergency forensic medicine unit based at a hospital (Compiegne, France). Guidelines are proposed for clinical examination of DFSA victims, clinical forensic medical examination, and accurate samplings for further toxicological and biological evidence.

Maxson RT; Yuma-Guerrero P; von Sternberg K; Lawson KA; Johnson KMK; Brown J et al. Screening for risky alcohol use among caregivers of pediatric trauma patients: A pilot study. Journal of Trauma, Injury, Infection and Critical Care 67(1, Supplement S): S37-S42, 2009. (28 refs.)

Background: Injury is the leading cause of death for children and has been linked to caregiver drinking. Screening and brief intervention for risky drinking has been successful in adult trauma centers but has not been evaluated in caregivers of pediatric trauma patients. The purpose of this study was to investigate a pilot screening process for risky drinking caregivers, to determine rates of risky alcohol use, and to assess potential relationships between risky drinking and child safety behaviors. Methods: Caregivers of pediatric trauma patients were screened by trained injury prevention educators. The screening assessed risky drinking, tobacco and illicit drug use, and child safety behaviors. Data were analyzed using descriptive analysis, frequency comparisons, and univariate logistic regression. Results: Over 7 months, 295 caregivers were screened; 32.5% (n = 96) screened positive for risky alcohol use. For 173 injured children, one caregiver was screened, and for 61 children, two caregivers were screened. In the one-caregiver group, 29% (n = 50) screened positive for risky drinking. For the two-caregiver group, in 18% (n = 11) of the cases, both caregivers screened positive, whereas in 39% (n = 24) only one caregiver screened positive. Males were more likely to screen positive (p < 0.01). Relationships between reported child safety behaviors and risky drinking were of interest, but not statistically significant. Conclusions: The results of our study demonstrate that a substantial number of caregivers of pediatric trauma patients will self-report risky drinking behaviors, and therefore, an opportunity exists for these families to receive the benefits of screening and brief intervention programs in pediatric trauma care settings.

McBeth BD; Ankel FK; Ling LJ; Asplin BR; Mason EJ; Flottemesch TJ; McNamara RM. Substance use in emergency medicine training programs. Academic Emergency Medicine 15(1): 45-53, 2008. (38 refs.)

Objectives: To explore the prevalence of substance use among emergency medicine (EM) residents and compare to a prior study conducted in 1992. Methods: A voluntary, anonymous survey was distributed in February 2006 to EM residents nationally in the context of the national in-service examination. Data regarding 43 substances, demographics, and perceptions of personal patterns of substance use were collected. Results: A total of 133 of 134 residencies distributed the surveys (99%). The response rate was 56% of the total EM residents who took the in-service examination (2,397/4,281). The reported prevalence of most illicit drug use, including cocaine, heroin, amphetamines, and other opioids, among EM residents are low. Although residents reporting past marijuana use has declined (52.3% in 1992 to 45.0% in 2006; p < 0.001), past-year use (8.8%-11.8%; p < 0.001) and past-month use (2.5%-4.0%; p < 0.001) have increased. Alcohol use appears to be increasing, including an increase in reported daily drinkers from 3.3% to 4.9% (p < 0.001) and an increase in number of residents who indicate that their consumption of alcohol has increased during residency (from 4% to 12.6%; p < 0.001). Conclusions: Self-reported use of most street drugs remains uncommon among EM residents. Marijuana and alcohol use, however, do appear to be increasing. Educators should be aware of these trends, and this may allow them to target resources for impaired and at-risk residents.

Melinda Mahabee-Gittens E; Gordon J; Krugh M; Henry B; Leonard A. A smoking cessation intervention plus proactive quitline referral in the pediatric emergency department: A pilot study. Nicotine & Tobacco Research 10(12): 1745-1751, 2008. (28 refs.)

The prevalence of adult tobacco users who utilize the emergency department as patients or parents is disproportionately higher than the national average rates of tobacco use. Thus, it is advised that the emergency department be utilized as a venue for providing tobacco cessation counseling to adult tobacco users. Using a randomized control trial design, this pilot study evaluated the effect of a brief tobacco cessation intervention for tobacco using parents of children brought to a pediatric emergency department. Participants received either usual care or a brief tobacco cessation intervention based on the first 2 of the 5A's of the Clinical Practice Guidelines and fax referral to the Quitline. The primary outcome was self-reported repeated point prevalence of tobacco use at 6 weeks and 3 months following the intervention. Secondary aims included number of quit attempts, increases in readiness to quit, comparisons of participants who were successfully retained, and contact rates by Quitline counselors. At 3-month follow-up, compared to the Usual Care Control group, intervention participants were more likely to have made at least one quit attempt (59% vs. 34%; p.01), be seriously thinking about quitting (68% vs. 37%; p.001), and have higher Ladder scores (6.2 vs. 5.3; p.05). Study personnel were able to contact 68% and 52%, respectively, of participants at 6-week and 3-month follow-up. Quitline counselors were unable to reach 54% of participants. Our results reveal increased intentions to quit and trends toward quitting, however we experienced difficulties with participant retention. Suggestions for improvements in point prevalence and retention are given.

Mello MJ; Longabaugh R; Baird J; Nirenberg T; Woolard R. DIAL: A telephone brief intervention for high-risk alcohol use with injured emergency department patients. Annals of Emergency Medicine 51(6): 755-764, 2008. (39 refs.)

Study objective: Brief interventions for high-risk alcohol use for injured emergency department (ED) patients have demonstrated effectiveness and may have a more pronounced effect with motor vehicle crash patients. We report on 3-month outcome data of a randomized controlled trial of injured patients, using a novel model of telephone-delivered brief interventions after ED discharge. Methods: ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, participants received by telephone an assessment of alcohol use and impaired driving and then were randomized to treatment (n=140) or standard care (n=145). Treatment consisted of 2 sessions of brief interventions done by telephone, focusing on risky alcohol use. At 3 months, both groups had an assessment of alcohol use and impaired driving. Results: Two hundred eighty-five patients were randomized and had a baseline mean Alcohol Use Disorders Inventory Test (AUDIT) score of 11.0 (SD=7.4). Three-month follow-up assessments were completed on 273 (95%). Mean AUDIT score decreased in both the treatment (mean change=-3.4; 95% confidence interval [CI] -4.5 to -2.3) and standard care group (mean change=-3.2; 95% CI -4.2 to -2.2). Measures of impaired driving decreased for the treatment group (mean change=-1.4 95%; CI -3.0 to 0.2) compared with standard care group (mean change=1.0; 95% CI -0.9 to 2.9; P=.04; d=0.31). Participants were stratified post hoc into 3 groups by baseline alcohol problem, with the treatment effect only being in the highest-scoring group (d=.30). Conclusion: Telephone brief interventions decreased impaired driving in our treatment group. Telephone brief intervention appears to offer an alternative mechanism to deliver brief intervention for alcohol in this at-risk ED population.

Mondragon L; Romero M; Borges G. Ethnography in an emergency room: Evaluating patients with alcohol consumption. Salud Publica de Mexico 50(4): 308-315, 2008. (17 refs.)

Objective. To present an ethnographic description of the treatment of patients with excessive alcohol consumption in an emergency room, how they are evaluated by doctors, and the various contextual aspects surrounding this condition. Materials and Methods. The ethnographic work was carried out over a period of two months, with researchers working 24 hours a day, seven days a week from January 9 to March 15, 2002 in the emergency room (ER) at General Hospital, Mexico City. Results. Patients that had consumed alcohol and were admitted to the ER had to wait longer than others to be treated for their intoxication to wear off and for their sometimes aggressive attitude to become calm. The rejection of the alcoholized patients was expressed through scolding to persuade alcohol-dependent patients or those that abused alcohol to reduce their consumption. Conclusion. The theoretical and methodological approach of the ethnographic observation enables reflection on the social and cultural mechanisms related to this health problem.

Mordal J; Bramness JG; Holm B; Morland J. Drugs of abuse among acute psychiatric and medical admissions: Laboratory based identification of prevalence and drug influence. General Hospital Psychiatry 30(1): 55-60, 2008. (28 refs.)

Objective: To use laboratory based analyses of blood and urine to determine the prevalence and influence of drugs of abuse among acute psychiatric and medical admissions. Method: In a cross sectional study, urine and blood samples were collected from 100 psychiatric and 106 medical admissions and extensively analysed for legal drugs with abuse potential, alcohol and illegal drugs. Drug influence at the time of admission was estimated on the basis of blood drug concentrations. Results: Legal drugs were found in 47% of the psychiatric and 42% of the medical admissions. Alcohol was detected in 8% of the psychiatric and 4% of medical admissions, and illegal drugs were detected in 36% of the psychiatric and 13% of the medical admissions. Drug influence was estimated in 26% of the psychiatric and 14% of the medical patients. Conclusion: This study shows widespread use of substances among psychiatric and medical inpatients and that many are under the influence of drugs on admission.

Murphy DA; Shetty V; Resell J; Zigler C; Yamnashita DD. Substance use in vulnerable patients with orofacial injury: Prevalence, correlates, and unmet service needs. Journal of Trauma Injury, Infection and Critical Care 66(2): 477-484, 2009. (58 refs.)

Background. A large portion of the injuries treated at urban trauma centers are preventable with alcohol and substance use presenting as common antecedent risk factors. Methods Alcohol and drug use characteristics of vulnerable adults treated for intentional orofacial injury at a regional trauma center were investigated. Patients (N = 154) presenting with intentional facial injury were recruited. Patients were considered eligible for recruitment if they were adults, recently used alcohol or drugs, and had a fracture within the 30 days preceding recruitment that involved the jaw, orbit, nose, or cheekbone as determined by clinical history, examination, and radiographic findings and that injury was due to interpersonal violence. Results: This patient cohort evidenced significant levels of alcohol use, with 58% of our patient cohort meeting the criteria for problem drinking. Although lower than alcohol use rates, the reported use of illicit drugs was substantial. Almost half of the sample reported other substance use in the previous month, with 24% meeting the criteria for problem drug use. Conclusions: Despite the very high percentage of individuals needing alcohol or drug treatment, only a small proportion of the patient sample reported having seen a professional for alcohol or drug treatment. Integrating substance use services into trauma care is discussed.

Neumann T; Helander A; Dahl H; Holzmann T; Neuner B; Weiss-Gerlach E et al. Value of ethyl glucuronide in plasma as a biomarker for recent alcohol consumption in the emergency room. Alcohol and Alcoholism 43(4): 431-435, 2008. (29 refs.)

Aim: This emergency department (ED) study compared the value of plasma ethyl glucuronide (EtG) testing with the information about alcohol consumption obtained using the standard alcohol biomarkers gamma-glutamyltransferase (GGT) and carbohydrate-deficient transferrin (CDT) and the AUDIT questionnaire. Methods: Minimally injured and clinically non-intoxicated male patients (n = 81) admitted to an ED were screened regarding their alcohol consumption, using the computerized AUDIT questionnaire and a paper-and-pencil assessment including the type, amount and time of alcohol intake. Blood samples were collected for determination of ethanol, EtG (LC-MS) and GGT in plasma and %CDT in serum (Axis-Shield %CDT immunoassay). Results: Out of the 81 patients, 23 (28%) were positive (>= 8 points) on the AUDIT questionnaire. Only 3 (4%) showed a detectable ethanol concentration (range 0.01-0.07 g/L) but 31 (38%) showed a detectable EtG (0.16-39.5 mg/L). In four patients, EtG was detectable in plasma for > 48 h after estimated completed elimination of ethanol. EtG was not correlated with the long-term biomarkers %CDT or GGT, or the AUDIT results, but with the time since estimated completed ethanol elimination. Conclusion: EtG testing in blood was found useful in the ED as a way to detect recent drinking, even in cases of a negative ethanol test, and to confirm abstinence from alcohol. This sensitive and specific short-term biomarker provides valuable additional information about individual drinking habits and might also be helpful to identify an alcohol hangover.

Neumann T; Neuner B; Weiss-Gerlach E; Lippitz F; Spies CD. Accuracy of carbon monoxide in venous blood to detect smoking in male and female trauma patients. Biomarkers in Medicine 2(1): 31-39, 2008. (22 refs.)

Background: The determination of the smoking status should be part of the initial assessment in emergency or surgery patients, as preventive measures might reduce long-term morbidity. Next to self-report (not always possible or reliable) the use of biomarkers such as carbon monoxide (CO) has been recommended. Point-of-care CO-hemoglobin (CO-Hb) determination is routinely used in trauma settings. The aim of this study was to evaluate the accuracy and the best cut-off of CO-Hb in order to determine the smoking status in minimally injured patients in the emergency department. Methods: After informed consent and ethical committee approval 1283 minimally injured patients were assessed in the emergency department immediately after admission with a computer-based questionnaire including the 'Heaviness of Smoking Index' questionnaire. Venous blood sampling and point-of-care oximetry, including CO-Hb, was performed. Results: Median age of all patients (smokers: males: 399, females: 176; nonsmokers: males: 420, females: 288) was 33 years. According to the receiver operating characteristics CO-Hb had an excellent ability to differentiate between smokers and nonsmokers (area under the curve: males: 0.949, females 0.932). Optimal CO-Hb cut-off was 1.8% in males (specificity 95.7%, sensitivity 85.5%) and 1.6% in females (specificity 96.9%, sensitivity 80.1%). Conclusion: CO-Hb was a good marker to detect current smoking in trauma patients. The cut-off of CO-Hb should be lowered to 1.6% in females and 1.8% in males.

Nielsen S; Dietze P; Cantwell K; Lee N; Taylor D. Methadone- and buprenorphine-related ambulance attendances: A population-based indicator of adverse events. Journal of Substance Abuse Treatment 35(4): 457-461, 2008. (19 refs.)

This study examined the nature and extent of methadone- and buprenorphine-related morbidity through a retrospective analysis of ambulance service records (N = 243) in Melbourne, Australia. Cases in which methadone and buprenorphine were implicated are examined. Demographic and presenting characteristics, transport outcomes, and other Substance use were explored. There were 84 buprenorphine-related attendances and 159 methadone-related attendances recorded on the database over the 4-year period. Presenting signs (respiratory rate and Glasgow Coma Scale score) were lower in the methadone-related attendances. Most of the attendances resulted in transport to hospital. Most presentations did not involve traditional signs of opioid overdose, a finding that warrants further investigation. This is the first article to describe characteristics of methadone- and buprenorphine-related ambulance attendances, with results suggesting this may be a useful way to monitor harms associated with these medications in the future.

Nilsen P; Baird J; Mello MJ; Nirenberg T; Woolard R; Bendtsen P et al. A systematic review of emergency care brief alcohol interventions for injury patients. (review). Journal of Substance Abuse Treatment 35(2): 184-201, 2008. (65 refs.)

This article examines 14 studies that assessed the effectiveness of brief interventions (BIs) delivered to injury patients in emergency care settings. The aims were to review findings concerning the effectiveness of providing BI in these settings and to explore factors contributing to its effectiveness. Of the 12 studies that compared pre- and post-BI results, 11 observed a significant effect of BI on at least some of the outcomes: alcohol intake, risky drinking practices, alcohol-related negative consequences, and injury frequency. Two studies assessed only post-BI results. More intensive interventions tended to yield more favorable results. BI patients achieved greater reductions than control group patients, although there was a tendency for the control group(s) to also show improvements. Five studies failed to show significant differences between the compared treatment conditions. Variations in the study protocol, alcohol-related recruitment criteria, screening and assessment methods, and injury severity limit the specific conclusions that can be drawn.

O'Connor G; McMahon G. Complications of heroin abuse. European Journal of Emergency Medicine 15(2): 104-106, 2008. (14 refs.)

A 21-year-old man presented to the emergency department in St James's Hospitalital by ambulance. He was found collapsed at home by his uncle. He was complaining of severe pain and swelling to his left lower limb, with reduced sensation to his left foot. He was hepatitis C positive from intravenous drug use, and had most recently used both heroin and cocaine 5 days previously on his release from prison. Musculoskeletal exam showed extensive swelling of his left lower limb, with tense calf compartments, Initial laboratory results showed a raised creatine kinase of more than 155 000 IU/I. Urine toxicology was positive for methadone, heroin and benzodiazepines, whereas urinary dipstick was positive for blood, which was confirmed to be myoglobin by subsequent laboratory analysis. Atraumatic rhabdomyolysis is a syndrome characterized by injury to skeletal muscle with subsequent release of intracellular contents, that is myoglobin and creatine kinase. Drugs have direct toxic effects, but may also cause coma-induced rhabdomyolysis, owing to unrelieved pressure on gravity-dependent body parts. Diagnosis is made with history (i.e. recent heroin or cocaine use), elevated serum CK, plus the possible presence of myoglobinuria. Aggressive IV rehydration remains the mainstay of treatment. If there is any evidence of compartment syndrome, urgent fasciotomy is required. Electrolyte imbalances should be corrected, unless very mildly abnormal. We have learned from our experience with this case that a high index of suspicion and thereby early recognition is crucial to prevent complications in intravenous drug users presenting with unusual symptoms and signs.

O'Phelan K; McArthur DL; Chang CWJ; Green D; Hovda DA. The impact of substance abuse on mortality in patients with severe traumatic brain injury. Journal of Trauma, Injury, Infection and Critical Care 65(3): 674-677, 2008. (31 refs.)

Background. Drug and alcohol use are common in neurotrauma patients. Despite growing methamphetamine use there are few studies of the impact of methamphetamine use on outcome after traumatic brain injury (TBI). Methods: We conducted a retrospective review of 5-years of data from a trauma database. Inclusion criteria included severe TBI and diagnosis codes indicating head injury. The entire database was analyzed and then a subset of patients with complete toxicology data were examined separately. Primary outcome was mortality. Results. Four hundred eighty-three patients were included. Toxicology resuits were available for 52.6% of patients. Alcohol, amphetamines, and cannabis were the most commonly detected substances. Overall mortality was 50.9%. When the group with complete tox screen data were analyzed, a toxicology screen that was positive for alcohol or amphetamine was associated with decreased mortality with an odds ratio of 0.23 (CI: 0.10-0.56, p = 0.001) and 0.25 (CI: 0.08-0.79, p = 0.02), respectively. When the subset of patients for whom toxicology data were available was analyzed the amphetamine-positive group was more likely to use cannabis and less likely to use alcohol. Conclusions. We unexpectedly found alcohol and methamphetamine use to be associated with decreased mortality. Neurotoxic and possible neuroprotective mechanisms of these substances are discussed as well as possible interactions between cannabis and methamphetamine. The potential influence of psycho-social factors are also considered. Prospective studies are needed to further investigate the effects of drug and alcohol use on outcome after severe TBI.

Osterman RL; Ribak J; Bohn CM; Fargo JD; Sommers MS. Screening for hazardous/harmful drinking and depressive symptoms in an at-risk emergency department population. Journal of Addictions Nursing 20(1): 34-40, 2009. (47 refs.)

Although co-occurring alcohol use and depression have been identified in many populations, wide-spread screening for these disorders has not occurred in many Emergency Departments (EDs). Co-morbidity of alcohol use and mood disorders places a person at increased risk for psychosocial and medical-physical problems. The purpose of this study was to investigate the association between hazardous/harmful alcohol use and depressive symptoms in an urban ED population of problem drinkers and risky drivers. Cross-sectional data from the baseline interview of a randomized controlled trial of a brief intervention protocol to reduce problem drinking and risky driving in the ED population were used to test the study hypothesis. Data were collected using the Health Interview Schedule, a modification of the WHO Composite Interview Schedule, with addition of the AUDIT questionnaire and the Center for Epidemiologyogic Studies Short Depression Scale (CES-D 10). Data from a sample of 255 individuals (68% male) were used in the present study (age: M = 28.38, CES-D 10: M = 9.79, SD = 6.22, AUDIT: M = 8.10, SD = 4.13). Multiple regression analyses indicated that total CES-D 10 scores were significantly associated with total AUDIT scores, drinks per week, income, and gender [F (4, 242) = 3.81, p = .005, R2 = .06]. Total AUDIT scores were positively associated with CES-D 10 scores (p .001). Due to co-morbidities associated with co-occurring depressive symptoms and hazardous/harmful drinking, it is imperative to assess ED patients for both of these conditions to provide expedient, optimal referral and treatment for patients at risk, particularly for patients injured in vehicular collisions because of their risky driving.

O'Toole TP; Pollini RA; Ford DE; Bigelow G. The health encounter as a treatable moment for homeless substance-using adults: The role of homelessness, health seeking behavior, readiness for behavior change and motivation for treatment. Addictive Behaviors 33(9): 1239-1243, 2008. (9 refs.)

Substance-using homeless persons frequent emergency departments and hospitals often. However, little is known about how homelessness affects when they seek care and their motivation for substance abuse treatment (SAT). We surveyed homeless (N=266) and non-homeless (N= 104) substance-using adults sequentially admitted to an urban hospital medicine service, comparing demographics, readiness for change (URICA), and motivating reasons for SAT. Homeless respondents were more likely to be younger, uninsured, have hepatitis B/C, and <12th grade education. The majority in both groups were in either a precontemplative or contemplative stage of change, although more homeless respondents were in an action stage. They also had similar motivating reasons for wanting SAT, although being homeless was an additional motivator for the majority of homeless respondents. Almost half reported that being homeless caused them to delay seeking health care; paradoxically those citing physical health as a SAT motivator were 3.4 times more likely to have delayed care. While acutely ill homeless persons were at least as motivated for SAT, these data suggest the challenge is getting them to care in a timely manner and tailoring interventions during the care episode to avail of this motivation.

Pletcher MJ; Kohn MA; Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. Journal of the American Medical Association 299(1): 70-78, 2008. (42 refs.)

Context: National quality improvement initiatives implemented in the late 1990s were followed by substantial increases in opioid prescribing in the United States, but it is unknown whether opioid prescribing for treatment of pain in the emergency department has increased and whether differences in opioid prescribing by race/ethnicity have decreased. Objectives: To determine whether opioid prescribing in emergency departments has increased, whether non-Hispanic white patients are more likely to receive an opioid than other racial/ethnic groups, and whether differential prescribing by race/ethnicity has diminished since 2000. Design and Setting: Pain-related visits to US emergency departments were identified using reason-for-visit and physician diagnosis codes from 13 years (1993-2005) of the National Hospital Ambulatory Medical Care Survey. Main Outcome Measure: Prescription of an opioid analgesic. Results: Pain-related visits accounted for 156,729 of 374,891 (42%) emergency department visits. Opioid prescribing for pain-related visits increased from 23% (95% confidence interval [CI], 21%-24%) in 1993 to 37% (95% CI, 34%-39%) in 2005 (P<.001 for trend), and this trend was more pronounced in 2001-2005 (P=.02). Over all years, white patients with pain were more likely to receive an opioid (31%) than black (23%), Hispanic (24%), or Asian/other patients (28%) (P<.001 for trend), and differences did not diminish over time (P=.44), with opioid prescribing rates of 40% for white patients and 32% for all other patients in 2005. Differential prescribing by race/ethnicity was evident for all types of pain visits, was more pronounced with increasing pain severity, and was detectable for long-bone fracture and nephrolithiasis as well as among children. Statistical adjustment for pain severity and other factors did not substantially attenuate these differences, with white patients remaining significantly more likely to receive an opioid prescription than black patients (adjusted odds ratio, 0.66; 95% CI, 0.62-0.70), Hispanic patients (0.67; 95% CI, 0.63-0.72), and Asian/other patients (0.79; 95% CI, 0.67-0.93). Conclusion: Opioid prescribing for patients making a pain-related visit to the emergency department increased after national quality improvement initiatives in the late 1990s, but differences in opioid prescribing by race/ethnicity have not diminished.

Poplas-Susic T; Komericki-Grzinic M; Klemenc-Ketis Z; Tusek-Bunc K; Zelko E; Kersnik J. Aetiological and demographical characteristics of acute poisoning in the Celje region, Slovenia. European Journal of Emergency Medicine 16(3): 127-130, 2009

Background: Data on emergency treatment of poisonings are scarce. Objective To determine the annual rate of poisoning-related emergency medical services (EMS) interventions and to determine the aetiology and demographic characteristics of poisoning cases. Methods: A prospective observational study included all poisoning-related intervention cases over 3 years (1999-2001) in the Celje region, Slovenia, covering 125 000 inhabitants. Data were recorded on an EMS form. Results Two hundred and forty-four poisoning-related EMS interventions were recorded among a total of 4486 interventions (5.4%) corresponding to an average annual rate of 0.56 poisonings per 1000 inhabitants per year. Psychoactive agents were detected in 56.5% of the cases. Two-thirds of the poisonings took place outside patients' home. In 30% of the cases, the administration of poison was because of suicidal intentions. The most common substance ingested was alcohol alone or in combination with prescription or illegal drugs in 42.6% of cases, followed by drugs alone or in combination with alcohol in 39.2% cases. More than one-fifth of the poisonings were because of the use of illegal drugs. At the time of the arrival of EMS 23.5% of the patients were in coma. EMS applied antidote in 23.2% of the patients. After emergency care, 9.3% of the patients were still in coma, 15.6% were comatose, 26.6% were somnolent, 18.6% were disoriented and 30% had complete consciousness. Of these, 84.4% of the patients were admitted to hospital or specialized care and 15.6% were sent back home. Conclusion: The pattern of poisoning is contrasted with that in other countries. The EMS proved to be a valuable resource for treatment of acute poisoning.

Ramchand R; Marshall GN; Schell TL; Jaycox LH; Hambarsoomians K; Shetty V et al. Alcohol abuse and illegal drug use among Los Angeles County trauma patients: Prevalence and evaluation of single item screener. Journal of Trauma, Injury, Infection and Critical Care 66(5): 1461-1467, 2009

Background: The misuse of alcohol and illicit drugs is implicated with injury and repeat injury. Admission to a trauma center provides an opportunity to identify patients with substance use problems and initiate intervention and prevention strategies. To facilitate the identification of trauma patients with substance use problems, we studied alcohol abuse and illegal substance use patterns in a large cohort of urban trauma patients, identified correlates of alcohol abuse, and assessed the utility of a single item binge-drinking screener for identifying patients with past 12-month substance use problems. Methods: Between February 2004 and August 2006, 677 patients from four large trauma centers in Los Angeles County were interviewed. The sample was broadly representative of the entire Los Angeles County trauma center patient population. Results: Twenty-four percent of patients met criteria for alcohol abuse and 15% reported using an illegal drug other than marijuana in the past 12 months. Male gender, assaultive injury, peritrauma substance use, and history of binge drinking were prominent risk factors. A single item binge drinking screen correctly identified alcohol abuse status in 76% of all patients; the screen also performed moderately well in discriminating between those who had or had not used illegal drugs in the past 12 months, with sensitivity estimates reaching 0.79 and specificity estimates reaching 0.74. Conclusions: A large proportion of urban trauma patients abuse alcohol and use illegal drugs. Distinct sociodemographic and substance use history may indicate underlying risky behaviors. Interventions and injury prevention programs need to address these causal behaviors to reduce injury morbidity and recidivism. In the busy trauma care setting, a one-item screener could be helpful in identifying patients who would benefit from more thorough assessment and possible brief intervention.

Roberts JR; Price C; Mazzeo T. Intravenous epiepherine: A minimally invasive treatment for priapism in the emergency department. Journal of Emergency Medicine 36(3): 285-289, 2009. (11 refs.)

Priapism is the prolonged erection of the penis in the absence of sexual arousal. A 45-year-old man, an admitted frequent cocaine user, presented to the Emergency Department (ED) on two separate occasions with a history of priapism after cocaine use. The management options in the ED, as exemplified by four individual case reports, in particular the use of a minimally invasive method of intracorporal epinephrine instillation, are discussed.

Roudsari B; Caetano R; Frankowski R; Field C. Do minority or white patients respond to brief alcohol intervention in trauma centers? A randomized trial. Annals of Emergency Medicine 54(2): 285-293, 2009. (389 refs.)

Study objective: The current study evaluates whether the effectiveness of brief alcohol intervention in reducing 6-and 12-month risk of injuries in a large Level I urban trauma center varies according to trauma patients' ethnicity. Methods: Eligible white, Hispanic, and black trauma patients aged 18 years or older were randomized to brief alcohol intervention or treatment as usual. The intervention was a "non-confrontational, patient-centered conversation" focused on patients' drinking pattern, with the purpose of encouraging them to change risky drinking. Study outcomes were patient-reported 6-and 12-month incidence of all-type injuries, alcohol-related injuries, and serious injuries (ie, injuries requiring emergency department visit or hospital admission). Results: A total of 1,493 trauma patients (668 whites, 537 Hispanics, 288 blacks) participated in this study. After 1 year of follow-up, we were not able to detect any important association between brief intervention and the risk of all-type injuries, alcohol-related injuries, or serious injuries among study participants. In addition, the association between brief intervention and the outcomes of interest was not modified by patients' ethnicity. Conclusion: Our study, congruent with some recent publications, implies that there are some patient-and provider-related impediments that could restrict the effectiveness of brief intervention programs in trauma centers, regardless of patient ethnicity. Unless those impediments are identified and eliminated, assuming that brief intervention will be an effective strategy for controlling future alcohol-related injuries among trauma patients and should be provided under any circumstances might not be reasonable.

Ryb GE; Cooler C. Outcomes of cocaine-positive trauma patients undergoing surgery on the first day after admission. Journal of Trauma, Injury, Infection and Critical Care 65(4): 809-812, 2008. (5 refs.)

Background: Concerns regarding complications of cocaine use are frequently used to justify delaying procedures among patients with positive urine cocaine toxicology (UCT); however, there is no evidence to support this practice. We investigated whether (UCT) patients experience a worse outcome than UCT-patients when undergoing surgery on the first day after admission to a trauma center. Methods: Files of adult trauma patients undergoing surgery during the first 24 hours after admission were selected from a trauma database. Patients without UCT testing were excluded. UCT+ and UCT- patients were compared in relation to mortality; length of stay; and the development of cardiac, infectious, and neurologic complications. Possible confounders were analyzed. Student's t test, Pearson's X-2 test, and Wilcoxon's statistics were used for analysis (alpha = 0.05). Multiple logistic regression models and Cox proportional hazard methods were used to adjust for possible confounders. Results. Of the 3,477 patients studied, 13% (n = 465) tested positive for cocaine. UCT+ patients had a different age distribution were more likely to be male and to have penetrating injury and had lower Injury Severity Scores than UCT-patients. Outcomes were similar for mortality (3% vs. 4%), for the development of infectious (18% and 19%) and neurologic (2% vs. 1%) complications, and median length of stay (5 days vs. 5 days). Cardiac complications were lower among the UCT+ patients (3% vs. 6%). Multiple logistic regression and Cox proportional hazard revealed results similar to those from the univariate analysis. conclusion: Outcomes after surgery during the first 24 hours after admission are not negatively affected by the presence of UCT+. An apparent protective effect of UCT+ status in the development of cardiac complications needs to be explained.

Schmidt S; Hugli O; Rizzo E; Lepori D; Gudinchet R; Yersin B et al. Detection of ingested cocaine-filled packets - Diagnostic value of unenhanced CT. European Journal of Radiology 67(1): 133-138, 2008. (24 refs.)

Purpose: Emergency departments are facing nowadays an increasing number of illegal drug-related health problems, associated with medicolegal and/or social consequences. Body stuffers are street cocaine dealers, who either store wrapped packets of drugs in their rectum or hastily swallow them, prompted by fear of police's arrest. These packets can be life threatening in case of leakage. We evaluate the diagnostic value of unenhanced multidetector CT (MDCT) for detection of cocaine-filled packets (CFP) ingested by body stuffers in a phantom model. Materials and methods: Our phantom simulated normal bowel contents in which a varying number of true and false UP were randomly mixed. Both only differ in radiological density. During 18 different reading sessions, four radiologists independently evaluated the presence and number of true and false CFP. Interobserver agreement, sensitivity, specificity, positive and negative predictive value were calculated. Results: Interobserver agreement for detection of any packets, for visualization of true, and false UP was good (kappa=0.63, 0.74 and 0.58, respectively). Sensitivity, specificity, positive and negative predictive value for detection of any packets was 95.6%, 100%, 100% and 62.5%, respectively; for visualization of the true UP 86.5%, 100%, 100% and 77.6%, respectively; and for the false packets 98.1%, 65%, 88.6% and 87.5%, respectively. Conclusion: Unenhanced MDCT without bowel preparation is a fast, reliable and easily reproducible imaging modality for the immediate detection of ingested UP, thus facilitating medicolegal management of body stuffers.

Schuckman H; Hazelett S; Powell C; Steer S. A validation of self-reported substance use with biochemical testing among patients presenting to the emergency department seeking treatment for backache, headache, and toothache. Substance Use & Misuse 43(5): 589-595, 2008. (20 refs.)

Purpose: This study tests the validity of self-reported illicit substance use against biochemical testing among Emergency Department (ED) patients seeking treatment with narcotics for backache, headache, and toothache and to characterize patients who provide false reports. Methods: Retrospective chart review comparing the self-reported drug use history obtained during an ED visit during a six-year period (1995-2001) with the results of a biochemical drug screen obtained the same day. Results: 248 patients met screening criteria, 79 (32%) of whom tested positive for unclaimed "drugs of abuse." Patients with a history of "drug abuse " and chronic pain were significantly more likely to test positive for unclaimed drugs than were their counterparts (p = .05 and p < .0001, respectively). No significant difference was found in comparing those with and without multiple ED visits or those requesting a specific narcotic. Conclusion: Self-reported drug use is unreliable in this ED subpopulation. When this knowledge is critical for patient care, biochemical testing may be indicated.

Silver GM; Albright JM; Schermer CR; Halerz M; Conrad P; Ackerman PD et al. Adverse clinical outcomes associated with elevated blood alcohol levels at the time of burn injury. Journal of Burn Care & Research 29(5): 784-789, 2008. (34 refs.)

Elevated blood alcohol content (BAC) on admission is associated with poorer outcomes, larger burns and more inhalation injury. This study's purpose was to examine the effects of alcohol through a matched case-controlled study, measuring early and extended markers of clinical outcomes. The hypothesis was that patients with an elevated admission BAC would require more resuscitation and have a longer hospital stay. Admissions 16 to 75 years of age with 15 to 75% TBSA and admission BACs were identified. Patients with BAC >30 mg/dl (BAC+, cases) were matched with patients with undetectable BAC (BAC-, controls), according to age, sex, TBSA, inhalation injury and mechanism. Screening identified 258 patients, 146 with admission BACs. Twenty-seven had a BAC 2: 30 mg/dl. There were 24 matched pairs. At 24 hours, BAC+ group had larger acute physiology and chronic health evaluation 11 scores (23.33 vs 18.75, P < .05), fluid requirements (5.25 vs 3.82 L (cc/kg/TBSA), P < .05), and base deficit (11.15 vs 7.15, P < .05). The duration of mechanical ventilation (14.85 vs 4.23 days, P < .05), intensive care unit length of stay (22.85 vs 9.38, P < .05), hospital length of stay (28.95 vs 15.68, P < .05), and mean hospital charges ($239,507 vs $144,598, P < .05) were increased in the BAC+ patients. Despite matched baseline injury characteristics, elevated BAC was associated with poorer short term and extended clinical outcomes, illustrating the impact of alcohol intoxication on physiologic derangement after burn injury.

Sindelar-Manning H; Lewander W; Chun T; Barnett N; Spirito A. Emergency department detection of adolescents with a history of alcohol abuse and alcohol problems. Pediatric Emergency Care 24(7): 457-461, 2008. (26 refs.)

Objective: To compare the characteristics of adolescents with and without a history of problematic alcohol use, who are treated in the emergency department (ED) for an alcohol-related problem. Methods: Three hundred seventeen adolescents presenting to the ED after an alcohol-related incident were divided into 2 groups based on whether their score on the Adolescent Drinking Inventory reached the clinical cutoff on problematic drinking, and compared regarding current drinking, depression, and risk-taking behaviors. Results: Adolescents who reached the clinical cutoff on the Adolescent Drinking Inventory were older and reported more frequent drinking, greater depressed mood, and more risk-taking behaviors. Conclusions: Of the adolescents presenting to the ED with an alcohol-related incident, those with a positive history of problematic drinking represent a particularly high-risk subgroup.

Stein LAR; Minugh PA; Longabaugh R; Wirtz P; Baird J; Nirenberg TD et al. Readiness to change as a mediator of the effect of a brief motivational intervention on posttreatment alcohol-related consequences of injured emergency department hazardous drinkers. Psychology of Addictive Behaviors 23(2): 185-195, 2009. (52 refs.)

Brief motivational interventions (BMIs) are usually effective for reducing alcohol use and consequences in primary care settings. We examined readiness to change drinking as a mediator of the effects of BMI on alcohol-related consequences. Participants were randomized into three conditions: (a) standard care plus assessment (SC), (b) SC plus BMI (BI), and (c) BI plus a booster session (BIB). At 12-month follow-tip BIB patients had significantly reduced alcohol consequences more than had SC patients. Patients receiving BI or BIB maintained higher readiness scores 3 months after treatment than did patients receiving SC. However, readiness mediated treatment effects only for those highly motivated to change prior to the intervention but not for those with low pre-intervention motivation. BI and BIB for these patients decreased alcohol consequences in part because they enhanced and maintained readiness for those highly motivated prior to the intervention, but not for those with low motivation. Results are opposite of what would be expected from MI theory. An alternative explanation is offered as to why this finding occurred with this opportunistically recruited Emergency Department patient population.

Tetrault JM; O'Connor PG. Substance abuse and withdrawal in the critical care setting. Critical Care Clinics 24(4): 767+, 2008. (97 refs.)

Substance use is common among individuals admitted to the critical care setting and may complicate treatment of underlying disorders. It is imperative for the critical care team to have a high index of suspicion for substance intoxication and withdrawal. This article reviews the epidemiology of substance use in this population and the treatment of common withdrawal syndromes. General principles regarding the management of substance withdrawal syndromes include general resuscitative measures, use of a symptom-triggered approach, and substitution of a long-acting replacement for the abused drug in gradual tapering dose. The authors stress the importance of long-term planning as part of the overall treatment protocol beyond the acute presentation.

Thapa PB; Walton MA; Cunningham R; Maio RF; Han XT; Savary PE. Longitudinal substance use following an emergency department visit for cocaine-associated chest pain. Journal of Drug Issues 38(4): 929-956, 2008. (85 refs.)

Substance abuse is a chronic, relapsing condition, yet some individuals over time seem to cease use for factors that are largely unclear. A life threatening episode of cocaine-associated chest pain requiring an emergency department (ED) visit may influence subsequent use. A consecutive cohort (n = 219) of patients who presented to a large, urban ED with cocaine-associated chest pain was interviewed at baseline, three months, six months, and 12 months to evaluate longitudinal rates of subsequent drug use. Overall, there was a significant decrease in cocaine use overtime (baseline = 100.0%, three months = 56.5%, six months = 54.2%, and 12 months = 51.7%, p <.05 for baseline versus each follow-up interval). Findings suggest that substance use declines following an ED visit for cocaine-related chest pain. However, about half of the subjects were still using cocaine one year later. Future studies examining the potential impact of brief interventions or case management to intervene with this not-in-treatment ED population are warranted.

Tonje L; Elisabeth S; Lars W. Handling of drug-related emergencies: an evaluation of emergency medical dispatch. European Journal of Emergency Medicine 16(1): 37-42, 2009. (27 refs.)

Aims: Documenting the quality of emergency dispatch centres handling of emergency calls regarding intoxicated unconscious patients. Methods: Interview with eight emergency dispatch centre directors and a nationwide survey among 313 dispatchers in Norway were performed. In addition, a customized scoring system was used to evaluate dispatcher log recordings of real cases. The recordings were compared with information from corresponding ambulance records. Results: Ninety-nine percent of the dispatchers stated that they used the Norwegian protocol for medical emergencies and 89% of them found it useful. The interviews, the survey, and the recordings, however, documented frequent deviation from the protocol. This instructs ambulance dispatch for any unconscious patient, but 21% stated that they would not dispatch any resource for an unconscious patient without further survey in alcohol-related cases. This was significantly more often (P < 0.05) than for the narcotic, combination and prescription -drug-related cases with 4, 10 and 7%, respectively. The recordings revealed deviation from the protocol with dispatchers only determining the patients' level of consciousness and respiratory status in 64 and 70% of the cases, respectively. For 16% of the cases, the dispatcher did not ask the caller about consciousness at all, even though these patients later were found with reduced consciousness. Conclusion: On the basis of the interviews and the survey, cases were handled according to guidelines. The log recordings, however, disclosed deviation from the protocol. Alcohol intoxication was associated with higher rate of deviation from the protocol compared with other intoxications.

Touquet R; Brown A. PAT. Revisions to the Paddington Alcohol Test for early identification of alcohol misuse and brief advice to reduce emergency department re-attendance. Alcohol and Alcoholism 44(3): 284-286, 2009. (12 refs.)

The Paddington Alcohol Test (PAT) has evolved over 15 years as a clinical tool to facilitate emergency physicians and nurses giving brief advice and the offer of an appointment for brief intervention by an alcohol nurse specialist. Previous work has shown that unscheduled emergency department re-attendance is reduced by 'making the connection' between alcohol misuse and resultant problems necessitating emergency care. The revised 'PAT (2009)' now includes education on clinical signs of alcohol misuse and advice on when to request a blood alcohol concentration.

Vroegop MP; Franssen EJ; van der Voort PHJ; van den Berg TNA; Langeweg RJ; Kramers C. The emergency care of cocaine intoxications. (review). Netherlands Journal of Medicine 67(4): 122-126, 2009. (30 refs.)

Cocaine is frequently used, especially among adolescents and by men between the age of 25 and 44. Many of them are able to use cocaine in normal day-to-day life, without any problems. Reduced prices of cocaine and other recreational drugs such as MDMA (ecstasy) and gamma hydroxybutyrate (GHB) has led to an increased incidence of intoxications with these drugs.' Since the production of cocaine is illegal, it may be impure and mixtures with other drugs such as atropine may occur. The treatment of patients with an acute cocaine intoxication can be complicated. Combination of cocaine with other drugs results in clinical pictures which are difficult to discriminate and that may have important consequences for treatment.

Walton MA; Cunningham R; Chermack ST; Tripathi S; Weber J; Maio RF et al. Predictors of violence following Emergency Department visit for cocaine-related chest pain. Drug and Alcohol Dependence 99(1-3): 79-88, 2009. (76 refs.)

This study examined 1-year violence outcomes among non-injured patients treated in the Emergency Department (ED) for cocaine-related chest pain. All urban Level I ED required patients with chest pain (age 60 and Younger) provide it Urine sample for cocaine testing. Cocaine-positive consenting patients (n=219) were interviewed in the ED; 80% completed follow-tip interviews over 12-months (n = 174; 59% males 79% African-American, mean age = 38.8, standard deviation 9.06; range = 19-60). Baseline rates of past year violent victimization and perpetration history were: 38% and 30%, respectively. During the 12-month follow-up, rates of victimization and perpetration outcomes were 35% and 30%, respectively. Predictors of violence outcomes (either victimization or perpetration) in the year post-ED visit based on characteristics were measured at baseline or during the follow-up period (i.e., gender, age, psychological distress, binge drinking days, cocaine use days, marijuana use days, substance abuse/dependence diagnosis, victimization/perpetration history). Victimization during the Follow-up was related to younger age, more frequent binge drinking and marijuana use at baseline, and victimization history, and to substance abuse/dependence, more frequent binge drinking, and psychiatric distress at follow-up. Specifically. participants who reported victimization at baseline were approximately 3 times, more likely to report victimization at 12-month follow-up. Perpetration during the follow-up was related to younger age and more frequent binge drinking at baseline, and to substance abuse/dependence, more frequent binge drinking, and psychiatric distress at follow-up. Overall, no significant gender differences were observed in violence; however, women were more likely than men to report injury during the most severe partner violence incident. Violence is a common problem among patients presenting to all inner-city ED for cocaine-related chest pain, with younger age and frequency of binge drinking being it consistent marker of continued violence involvement. Intervention approaches to link these not-in-treatment cocaine users to services and reduce cocaine use must take into account concomitant alcohol Mmsuse and violence.

Walton MA; Goldstein AL; Chermack ST; McCammon RJ; Cunningham RM; Barry KL et al. Brief alcohol intervention in the emergency department: Moderators of effectiveness. Journal of Studies on Alcohol and Drugs 69(4): 550-560, 2008. (66 refs.)

Objective: Prior research supports the effectiveness of brief interventions for reducing alcohol misuse among patients in the emergency department (ED). However, limited information is available regarding the mechanisms of change, which could assist clinicians in streamlining or amplifying these interventions. This article examines moderators of outcomes among ED patients, ages 19 and older, who participated in a randomized controlled trial of a brief intervention for alcohol misuse. Method: Injured patients (N = 4,476) completed a computerized survey; 575 at-risk drinkers were randomly assigned to one of four brief intervention conditions, and 85% were interviewed again at 3-month and 12-month follow-ups. Results: Regression models using the generalized estimating equations approach examined interaction effects between intervention condition (advice/no advice) and hypothesized moderator variables (stage of change, self-efficacy, acute alcohol use, attribution of injury to alcohol) on alcohol outcomes over time. Overall, participants who reported higher levels of self-efficacy had lower weekly consumption and consequences, whereas those with higher readiness to change had greater weekly consumption and consequences. Furthermore, individuals who attributed their injury to alcohol and received advice had significantly lower levels of average weekly alcohol consumption and less frequent heavy drinking from baseline to 12-month follow-up compared with those who attributed their injury to alcohol but did not receive advice. Conclusions: This study provides novel data regarding attribution for alcohol-related injury as an important moderator of change and suggests that highlighting the alcohol/injury connection in brief, ED-based alcohol interventions can augment their effectiveness.

Weiss-Gerlach E; Franck M; Neuner B; Gentilello LM; Neumann T; Tonnesen H et al. Motivation of trauma patients to stop smoking after admission to the emergency department. Addictive Behaviors 33(7): 906-918, 2008. (38 refs.)

Every smoker should be offered smoking cessation treatment when they present for clinical care. The Readiness to Change-Smokers (RTC-S) questionnaire and the Heidelberg Smoking History (HSH) are brief questionnaires that divide patients into three stages. The purpose of this study was to prospectively compare the performance of each questionnaire at identifying patients who will successfully quit smoking within one year of Emergency Department (ED) discharge. Out of 1292 injured ED patients nearly half(n = 599, 46.4%)were identified as current smokers. Both questionnaires were given to all 599 subjects, and used to divide patients into three stages. At 12-months postdischarge 306 patients (51.1%) were contacted to determine smoking status. Patients were similarly classified by both tests in only 36% of cases. Concordance between tests was poor (kappa = 0.33). The Readiness to Change-Smokers text classified fewer patients as ready to quit (A = 13% vs. 22.2%). At 12 month follow-up, 55 patients (17.9%) had stopped smoking. The Heidelberg Smoking History was more successful to predict quitters. Multivariate logistic regression with respect to smoking cessation resulted in significant impact of Heidelberg Smoking History (P = 0.024).

Wood DM; Greene SL; Alldus G; Huggett D; Nicolaou M; Chapman K et al. Improvement in the pre-hospital care of recreational drug users through the development of club specific ambulance referral guidelines. Substance Abuse Treatment, Prevention and Policy 3: e-article 14, 2008. (12 refs.)

Background: Previously developed 'club guidelines' developed for club owners and promoters have tended to focus more on the legislative aspects of clubs, rather than the medical management of unwell clubbers within club environments. Despite this lack of guidance on the management of unwell clubbers, a significant proportion of clubs have 'club medic' rooms for managing these individuals. However, due to the lack of specific guidance on the training of staff working in these rooms and guidelines on when an ambulance should be called for an unwell clubber, there have been instances previously where clubbers have been inappropriately managed within the club environment, and often referred to hospital only after significant physiological derangement has occurred, thereby leading to an increased risk of morbidity and mortality. Methods: We identified owners and promoters of local club venues within the catchment area of our Emergency Department and working jointly with them and other key stakeholders, in particular the London Ambulance Service and Metropolitan Police, identified strategies to improve pre-hospital care for clubbers who become unwell as a result of recreational drug use. These included developing guidelines detailing indications for ambulance transfer to hospital for clubbers with recreational drug toxicity and the training of club medic staff to use the guidelines Results: Following the initial development of a pilot set of guidelines, an audit of their use identified training needed relating to the assessment of unwell clubbers with recreational drug toxicity and revisions required to the pilot version of the guidelines. After training related to the revised guidelines, all the club medic staff were confident in their ability to assess unwell clubbers with recreational drug toxicity, the use of the guidelines and also when to call an ambulance. Conclusion: Working with key stakeholders in the local community, we have developed guidelines that can be used to improve the pre-hospital care of clubber unwell with recreational drug toxicity, and demonstrated that individuals with a variety of medical knowledge can be trained to use these guidelines. Wider dissemination of these guidelines, both regionally, nationally and potentially internationally, may help to reduce the pre-hospital morbidity and mortality associated with recreational drug toxicity encountered in club environments.

Wood DM; Warren-Gash C; Ashraf T; Greene SL; Shather Z; Trivedy C et al. Medical and legal confusion surrounding gamma-hydroxybutyrate (GHB) and its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (1,4BD). QJM. An International Journal of Medicine 101(1): 23-29, 2008. (33 refs.)

Background: Gamma-hydroxybutyrate (GHB) is used as a recreational drug, with significant associated morbidity and mortality; it is therefore a class C drug under the Misuse of Drugs Act (1971). However, its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (1,4BD) remain legally available despite having similar clinical effects. Aim: The aim of this study was to determine whether the relative proportions of self-reported ingestions of GHB or its precursors GBL and 1,4BD were similar to those seen in analysis of seized drugs. Design and methods: Retrospective review of our clinical toxicology database to identify all cases of self-reported recreational GHB, GBL and 1,4BD use associated with ED presentation in 2006. Additionally all seized substances on people attending local club venues were analysed by a Home Office approved laboratory to identify any illicit substances present. Results: In 2006, there were a total of 158 ED presentations, of which 150 (94.9) and 8 (5.1) were GHB and GBL self-reported ingestions respectively; 96.8 (153) were recreational use. Of the 418 samples seized, 225 (53.8) were in liquid form; 85 (37.8) contained GHB and 140 (62.2) contained GBL. None of the seized samples contained 1,4BD and there were no self-reported 1,4BD ingestions. Conclusions: Self-reported GHB ingestion was much more common than GBL ingestion, whereas GBL was more commonly found in the seized samples. These differences suggest that GBL use may be more common than previously thought and we suggest that there should be further debate about the legal status of the precursors of GHB.