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CORK Bibliography: Emergency Medicine

99 citations. January 2010 to present

Prepared: September 2012

Anders ME; Sheffer CE; Barone CP; Holmes TM; Simpson DD; Duncan AM. Emergency department-initiated tobacco dependence treatment. American Journal of Health Behavior 35(5): 546-556, 2011. (41 refs.)

Objective: To examine the feasibility of a fax referral program to increase enrollment in tobacco dependence treatment in emergency department (ED) patients. Methods: The control group received quit advice and printed information; the intervention group also received a faxed referral that generated telephone contacts. Results: Treatment enrollment was higher in the intervention group (13.5% vs 2.7%). Only the faxed referral was associated with treatment enrollment. Conclusions: An ED intervention is feasible. Faxed referral resulted in a 5-fold increase in tobacco treatment enrollment. The ED may be an opportune setting to facilitate smoking-cessation behavior change among lower income, underserved patients.

Andolfatto G; Willman E. A prospective case series of single-syringe ketamine-propofol (Ketofol) for emergency department procedural sedation and analgesia in adults. Academic Emergency Medicine 18(3): 237-245, 2011. (52 refs.)

Objectives: The objective was to evaluate the effectiveness, recovery time, and adverse event profile of intravenous (IV) mixed 1:1 ketamine-propofol (ketofol) for adult procedural sedation and analgesia (PSA) in the emergency department (ED). Methods: Prospective data were collected on all PSA events over a 4.5-year period in a trauma-receiving suburban teaching hospital. PSAs using a 1:1 single-syringe mixture of 10 mg/mL ketamine and 10 mg/mL propofol in patients over 21 years of age were analyzed. Physiologic data, drug doses, adverse events, recovery time, patient satisfaction, and staff satisfaction were recorded. Results: Ketofol PSA was used in 728 patients for primarily orthopedic procedures. Median patient age was 53 years (range = 21 to 99 years, interquartile range [IQR] = 36-70 years). The median dose of ketamine and propofol was 0.7 mg/kg each (range = 0.2 to 2.7 mg/kg, IQR = 0.5-0.9 mg/kg), and median recovery time was 14 minutes (range = 3 to 50 minutes, IQR = 10-17 minutes). PSA was effective in 717 cases (98%). Bag-mask ventilation occurred in 15 patients (2.1%; 95% confidence interval [CI] = 1.0% to 3.1%). Recovery agitation occurred in 26 patients (3.6%; 95% CI = 2.2% to 4.9%), of whom 13 (1.8%; 95% CI = 0.8% to 2.7%) required treatment. One patient experienced vomiting and one patient was admitted to the hospital for monitoring of transient dysrhythmia and hypotension. No sequelae were identified. The median staff satisfaction scores were 10 (IQR = 9-10) on a scale of 1 to 10, and 97% of patients would have chosen the same method of PSA in the future. Conclusions: Ketofol is an effective PSA agent in adult ED patients. Recovery times are short and adverse events are few. Patients and ED staff were highly satisfied.

Attema-de Jonge ME; Peeters SYG; Franssen EJF. Performance of three point-of-care urinalysis test devices for drugs of abuse and therapeutic drugs applied in the emergency department. Journal of Emergency Medicine 42(6): 682-691, 2012. (30 refs.)

Background: Point-of-care tests for toxicological screening of patients for drugs of abuse and therapeutic drugs may be helpful in the emergency department (ED) to assist in a rapid diagnosis. Objectives: In this prospective study, the performance of TesTcard9 (R) (Varian; Middelburg, Netherlands), Syva Rapid Test d.a.u. 10 (R) (Dade Behring; Leusden, Netherlands), and Triage TOX Drug Screen (R) (Biosite; Bunnik, Netherlands), when applied on-site in the ED by physicians and nurses, was evaluated. Methods: Patients in the ED were included in the study when a physician thought the patient could benefit from a toxicological screen. Urine samples were screened utilizing the three point-of-care tests. All three tests simultaneously determined the presence of amphetamines, methamphetamine, opiates, methadone (except for TesTcard9), cocaine, cannabis, barbiturates, benzodiazepines, tricyclic antidepressants, and phencyclidine. The same urine specimen was analyzed in the pharmacy department using Syva EMIT II immunoassay and chromatographic confirmation. The results were compared for agreement. Results: During the 6-month study period, 80 urine samples were screened. In total, 62 (78%) specimens were found positive for at least one drug. Amphetamines (n = 16), cocaine (n = 27), cannabis (n = 25), benzodiazepines (n = 25), and opiates (n = 8) were the most frequently found. The sensitivity and specificity of all three devices were higher than 93% for these compounds, with the exception of the sensitivity for cannabis with the TesTcard9 (88%) and the sensitivity for benzodiazepines with the Syva RapidTest d.a.u. 10 (88%) and TesTeard9 (80%). Conclusion: In the ED setting, the Triage TOX Drug Screen performed better than the other point-of-care tests, probably due to its more objective reading system and its adequate quality controls.

Babu KM; Zuckerman MD; Cherkes JK; Hack JB. First-onset seizure after use of 5-hour Energy. Pediatric Emergency Care 27(6): 539-540, 2011. (17 refs.)

The health consequences of energy drink use in adolescents are unknown. We discuss an adverse event in an adolescent who presented to the emergency department with his first-ever seizure after consumption of 5-Hour Energy. We review the typical presentation of caffeine toxicity, as well as the importance of screening for energy drink use in adolescents with appropriate clinical findings. We pay particular attention to the identification of energy drink-related adverse events in the emergency department and the need for subsequent reporting to the Food and Drug Administration. To our knowledge, this is the first reported case of an adolescent presenting with a new-onset seizure associated with energy drink use.

Baumann BM; Mazzarelli A; Brunner J; Chansky ME; Thompson N; Boudreaux ED. Purchase and use patterns of heroin users at an inner-city emergency department. Journal of Emergency Medicine 42(1): 93, 2012. (14 refs.)

Background: Many consider heroin abuse a problem of the inner city, but suburban patients may also be at risk. Objective: To characterize the demographics and purchase/use patterns of heroin users in an inner-city emergency department (ED). Methods: The study was conducted in one of the most impoverished and crime-ridden cities in the United States. Demographics and substance use habits of ED patients were prospectively collected. Patients who were < 18 years of age, cognitively impaired, or did not speak English were excluded. Participants were further categorized as homeless, inner-city, and suburban residents. Results: Of 3947 participants, 608 (15%) used an illicit substance in the past year, with marijuana (9%) and cocaine (6%) the most commonly used. Heroin ranked third, used by 180 (5%) participants, with 61% male, 31% black, and 20% Hispanic. There were 64 homeless, 60 suburban, and 56 inner-city heroin users. The most common route of use was injection (68%), with the highest rate in the homeless (84%). The majority of homeless and inner-city users bought (73%, both groups) and used (homeless 74%, inner city 88%) in the inner city. Of suburban users, 58% purchased and 61% used heroin in the inner city. Prescription narcotic use was more common in homeless (20%) and suburban (23%) heroin users than in inner-city users (9%) (p < 0.001). Conclusions: Heroin is the third most commonly used illicit substance by ED patients, and a significant amount of inner-city purchase and use activity is conducted by suburban heroin users.

Bell L; Stargatt R; Bosanac P; Castle D; Braitberg G; Coventry N. Child and adolescent mental health problems and substance use presentations to an emergency department. Australasian Psychiatry 19(6): 521-525, 2011. (14 refs.)

Objective: The aim of this study was to determine the characteristics and referral pattern of children and adolescents with mental health problems, substance misuse and comorbidity presenting to the emergency department (ED) of a large public hospital. Method: A file audit of the ED information system was conducted over a 12 month period. Outcome measures included age, gender, diagnostic presentation, assessment, referral and disposal. Results: Forty-four substance misuse, 128 mental health and 82 comorbidity presentations were identified; 80% required treatment within 30 minutes. Few substance misuse cases were seen by mental health services and no substance misuse cases were referred for mental health service assessment. All mental health and comorbidity cases were seen by mental health services; 41% were referred to outpatient and 18% to inpatient services. Those with mental health problems displayed high levels of self-mutilation, and those with comorbidity displayed high levels of self-mutilation and substance misuse. Alcohol use was common in the substance misuse group, and over the counter or prescription medications were abused by the mental health and comorbidity groups. Conclusions: This age group places a high demand on the ED. All children and adolescents with recognized mental health symptoms were seen by mental health services, but those with substance misuse were not. Given the long-term problems associated with substance misuse, this is a missed opportunity for intervention.

Bernstein E; Ashong D; Heeren T; Winter M; Bliss C; Madico G. The impact of a brief motivational intervention on unprotected sex and sex while high among drug-positive emergency department patients who receive STI/HIV VC/T and drug treatment referral as standard of care. AIDS & Behavior 16(5): 1203-1216, 2012. (33 refs.)

This randomized, controlled trial, conducted among out-of-treatment heroin/cocaine users at an emergency department visit, tests the impact on sexual risk of adding brief motivational intervention (B-MI) to point-of-service testing, counseling and drug treatment referral. 1,030 enrollees aged 18-54 received either voluntary counseling/testing (VC/T) with drug treatment referral, or VC/T, referral, and B-MI, delivered by an outreach worker. We measured number and proportion of non-protected sex acts (last 30 days) at 6 and 12 months ( = 802). At baseline, 70% of past-30-days sex acts were non-protected; 35% of sex acts occurred while high; 64% of sexual acts involved main, 24% casual and 12% transactional sex partners; 1.7% tested positive for an STI, and 8.8% for HIV. At six or 12 month follow-up, 20 enrollees tested positive for Chlamydia and/or Gonorrhea, and 6 enrollees HIV sero-converted. Self-reported high-risk behaviors declined in both groups with no significant between-group differences in behaviors or STI/HIV incidence.

Bernstein SL; Bijur P; Cooperman N; Jearld S; Arnsten JH; Moadel A et al. A randomized trial of a multicomponent cessation strategy for emergency department smokers. Academic Emergency Medicine 18(6): 575-583, 2011. (54 refs.)

Objectives: The objective was to determine the efficacy of an emergency department (ED)-based smoking cessation intervention. Methods: This study was a randomized trial conducted from January 2006 to September 2007 at an urban ED that treats 90,000 adults per year. Discharged adults who smoked at least 10 cigarettes per day were randomized to 1) usual care, receiving a smoking cessation brochure; or 2) enhanced care, receiving the brochure, a motivational interview (MI), nicotine patches, and a phone call at 3 days. Interventions were performed by a peer educator trained in tobacco treatment. Blinded follow-up was performed at 3 months. Results: A total of 338 subjects were enrolled, mean (+/-SD) age was 40.2 (+/-12.0) years, 51.8% were female, and 56.5% were either self-pay or Medicaid. Demographic and clinical variables were comparable between groups. Enhanced and usual care arms showed similar cessation rates at 3 months (14.7% vs. 13.2%, respectively). The proportion of subjects making a quit attempt (69.2% vs. 66.5%) and decrease in daily cigarette use (five vs. one; all p > 0.05) were also similar. In logistic modeling, factors associated with quitting included any tobacco-related International Classification of Diseases, ninth revision (ICD-9), code for the ED visit (odds ratio [OR] = 3.42, 95% confidence interval [CI] = 1.61 to 7.26) or subject belief that the Ell visit was tobacco-related (OR = 2.47, 95% CI = 1.17 to 5.21). Conversely, subjects who reported having a preexisting tobacco-related illness were less likely to quit (OR = 0.22, 95% CI = 0.10 to 0.50). Conclusions: The primary endpoint was negative, reflecting a higher-than-expected quit rate in the control group. Subjects whose ED visit was tobacco-related, based either on physician diagnosis or subject perception, were more than twice as likely to quit. These data suggest that even low-intensity screening and referral may prompt substantial numbers of ED smokers to quit or attempt to quit.

Bilello J; McCray V; Davis J; Jackson L; Danos LA. Acute ethanol intoxication and the trauma patient: Hemodynamic pitfalls. World Journal of Surgery 35(9): 2149-2153, 2011. (24 refs.)

Many trauma patients are acutely intoxicated with alcohol. Animal studies have demonstrated that acute alcohol intoxication inhibits the normal release of epinephrine, norepinephrine, and vasopressin in response to acute hemorrhage. Ethanol also increases nitric oxide release and inhibits antidiuretic hormone secretion. This article studies the effects of alcohol intoxication (measured by blood alcohol level, BAL) on the presentation and resuscitation of trauma patients with blunt hepatic injuries. A retrospective registry and chart review was conducted of all patients who presented with blunt liver injuries at an ACS-verified, level I trauma center. Data collected included admission BAL, systolic blood pressure, hematocrit, International Normalized Ratio (INR), liver injury grade, Injury Severity Score (ISS), intravenous fluid and blood product requirements, base deficit, and mortality. From September 2002 to May 2008, 723 patients were admitted with blunt hepatic injuries. Admission BAL was obtained in 569 patients, with 149 having levels > 0.08%. Intoxicated patients were more likely to be hypotensive on admission (p = 0.01) despite a lower liver injury grade and no significant difference in ISS. There was no significant difference in the percent of intoxicated patients requiring blood transfusion. However, when blood was given, intoxicated patients required significantly more units of packed red blood cells (PRBC) than their nonintoxicated counterparts (p = 0.01). Intoxicated patients also required more intravenous fluid during their resuscitation (p = 0.002). Alcohol intoxication may impair the ability of blunt trauma patients to compensate for acute blood loss, making them more likely to be hypotensive on admission and increasing their PRBC and intravenous fluid requirements. All trauma patients should have BAL drawn upon admission and their resuscitation should be performed with an understanding of the physiologic alterations associated with acute alcohol intoxication.

Bogenschutz MP; Donovan DM; Adinoff B; Crandall C; Forcehimes AA; Lindblad R et al. Design of National Institute on Drug Abuse CTN Protocol 0047: Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED). American Journal of Drug and Alcohol Abuse 37(5): 417-425, 2011. (53 refs.)

Background: Medical settings such as emergency departments (EDs) present an opportunity to identify and provide services for individuals with substance use problems who might otherwise never receive any form of assessment, referral, or intervention. Although screening, brief intervention, and referral to treatment models have been extensively studied and are considered effective for individuals with alcohol problems presenting in EDs and other medical settings, the efficacy of such interventions has not been established for drug users presenting in EDs. Objectives: This article describes the design of a National Institute on Drug Abuse Clinical Trials Network protocol testing the efficacy of an screening, brief intervention, and referral to treatment model in medical EDs, highlighting considerations that are pertinent to the design of other studies targeting substance use behaviors in medical treatment settings. Methods: The protocol is described, and critical design decisions are discussed. Results: Design challenges included defining treatment conditions, study population, and site characteristics; developing the screening process; choosing the primary outcome; balancing brevity and comprehensiveness of assessment; and selecting the strategy for statistical analysis. Conclusion: Many of the issues arising in the design of this study will be relevant to future studies of interventions for addictions in medical settings. Scientific Significance: Optimal trial design is critical to determining how best to integrate substance abuse interventions into medical care.

Bogstrand ST; Normann PT; Rossow I; Larsen M; Morland J; Ekeberg O. Prevalence of alcohol and other substances of abuse among injured patients in a Norwegian emergency department. Drug and Alcohol Dependence 117(2-3): 132-138, 2011. (28 refs.)

Background: Studies have found a high prevalence of both alcohol and other impairing psychoactive drugs in injured patient populations. The aim of this study was to assess the prevalence of potentially impairing psychoactive substances in all patients admitted to a hospital emergency department with injuries from accidents, assault or deliberate self harm. Methods: A total of 1272 patients over 18 years of age, admitted to the hospital within 12 h of injury, were included. Presence of alcohol was determined by an enzymatic method and other drugs by liquid chromatography-mass spectrometry (LC-MS) or gas chromatography-mass spectrometry (GC-MS), both highly specific analytical methods for determining recent intake. Results: There were 510(40%) women in the sample. Of the patients, 38% of the women and 48% of the men had a positive blood sample for psychoactive substances on admission. The most prevalent psychoactive substance was alcohol (27%) with an average concentration of 1.5 g/kg. A further 21% of patients tested showed use of medicinal drugs, and 9% showed use of illicit substances. Cannabis was the most prevalent illicit drug (6.2%). Diazepam (7.4%) and zopiclone (5.3%) were the most prevalent medicinal drugs. In road traffic accidents, 25% of the car drivers had positive findings, about half of them for alcohol. Conclusion: Psychoactive substances were found in nearly half the patients admitted with injuries. The most common substance was alcohol. Alcohol was particularly related to violence, whereas medicinal drugs were most prevalent in accidents at home.

Bond J; Ye Y; Cherpitel CJ; Borges G; Cremonte M; Moskalewicz J et al. Scaling properties of the combined ICD-10 dependence and harms criteria and comparisons with DSM-5 alcohol use disorder criteria among patients in the emergency department. Journal of Studies on Alcohol and Drugs 73(2): 328-336, 2012. (26 refs.)

Objective: The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), and the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), alcohol use disorders (AUDs) classifications offer competing and somewhat overlapping diagnostic tools for assessing alcohol dependence and harms/abuse. Both systems are in active stages of development in anticipation of their next respective iterations. Although much psychometric work has been done studying DSM-IV criteria, efforts toward the ICD-11 have been less prevalent. Method: Data from 3, 191 drinkers in seven emergency department sites in four countries (United States, Mexico, Argentina, and Poland) were used to study the psychometric properties of the combined ICD-10 dependence and harms criteria. Comparisons with the proposed set of DSM-5 criteria and diagnostic thresholds are also included. Results: Item response theory analyses of the combined ICD-10 dependence and harms criteria suggested a single underlying factor, both overall and for each site separately, with only moderate differential item functioning across sites. Overall agreement between the summative combined ICD-10 dependence and harms criteria and the proposed 11-criteria DSM-5 scale was very high (r = .97), as was agreement between proposed diagnostic threshold levels of 0-1 (negative AUD), 2-3 (moderate AUD), and 4 or more (severe AUD) criteria endorsed (kappa = .84). Although disagreement between the two three-level diagnoses was only 5.5% of the sample, a majority of these were because of differences between endorsement rates of abuse versus harms criteria. Conclusions: Although there is support for efforts to align the two schemes, results are consistent with other studies finding the largest differences between the two systems emanating from differences between the abuse and harms domains. More research is needed before differences between the two systems can be reconciled.

Booth BM; Walton MA; Barry KL; Cunningham RM; Chermack ST; Blow FC. Substance use, depression, and mental health functioning in patients seeking acute medical care in an inner-city ED. Journal of Behavioral Health Services & Research 38(3): 358-372, 2011. (69 refs.)

The study investigated the behavioral health of a consecutive sample of 5,641 adult emergency department (ED) patients aged 19 through 60 presenting for medical care in a large, inner-city hospital ED. Twenty-three percent met the criteria for major depression; average mental health functioning, as measured by the mental health component of the SF-12, was half of a standard deviation lower than in the general population; 15% met the criteria for alcohol or drug abuse/dependence in the past year. Comorbidity was high. These behavioral health disorders may complicate treatment and diagnosis of the chief presenting complaint. These findings, coupled with the high rates of these disorders, suggest the importance of screening and either beginning appropriate treatment or offering appropriate referral for such disorders in ED settings.

Boyer EW. Drug Therapy: Management of opioid analgesic overdose. New England Journal of Medicine 367(2): 146-155, 2012. (78 refs.)

Opioid analgesic overdose is a preventable and potentially lethal condition that results from prescribing practices, inadequate understanding on the patient's part of the risks of medication misuse, errors in drug administration, and pharmaceutical abuse. Three features are key to an understanding of opioid analgesic toxicity. First, opioid analgesic overdose can have life-threatening toxic effects in multiple organ systems. Second, normal pharmacokinetic properties are often disrupted during an overdose and can prolong intoxication dramatically. Third, the duration of action varies among opioid formulations, and failure to recognize such variations can lead to inappropriate treatment decisions, sometimes with lethal results. The author reviews the epidemiology of overdose; the pathophysiology and the toxicokinetics of opioid analgesics; the clinical manifestations of overdose; diagnosis of overdose; management of overdose; considerations in special populations, particularly children and the elderly; common pitfalls in clinical management with attention to the use of naloxone (the antidote naloxone may have limited effectiveness in patients with poisoning from long-acting agents.) The unpredictable clinical course of intoxication demands empirical management of this potentially lethal condition; and prevention of overdose.

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The DAWN Report: Emergency Department Visits Involving Energy Drinks. (November 22, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (10 refs.)

Energy drinks are flavored beverages containing high amounts of caffeine and typically other additives, such as vitamins, taurine, herbal supplements, creatine, sugars, and guarana, a plant product containing concentrated caffeine. These drinks are sold in cans and bottles and are readily available in grocery stores, vending machines, convenience stores, and bars and other venues where alcohol is sold. These beverages provide high doses of caffeine that act as a stimulant upon the central nervous system and cardiovascular system. The total amount of caffeine in a can or bottle of an energy drink varies from about 80 to more than 500 milligrams (mg) of caffeine, compared with about 100 mg in a 5-ounce cup of coffee or 50 mg in a 12-ounce cola. Research suggests that certain additives may compound the stimulant effects of caffeine. Some types of energy drinks may also contain alcohol, producing a hazardous combination; however, this report focuses only on the dangerous effects of energy drinks that do not have alcohol. Trend data show a sharp increase in the number of emergency department (ED) visits involving energy drinks between 2005 (1,128 visits) and 2008 and 2009 (16,053 and 13,114 visits, respectively), representing about a tenfold increase between 2005 and 2009. Approximately half of the energy drink related ED visits (52 percent) made by patients aged 18 to 25 involved combinations of energy drinks with alcohol or other drugs. Overall, more ED visits involving energy drinks were made by males (64%) than by females (36%), and visits by males were more likely than visits by females to involve energy drinks in combination with alcohol (20 vs. 10%) or illicit drugs (12 vs. 5%); visits made by females were more likely to involve energy drinks in combination with pharmaceuticals than visits by males (35 vs. 23%) ?? When examined by the reason for the ED visit, more than two thirds (67%) of visits involving energy drinks were classified as adverse reactions

Public Domain

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2009: Methodology Report. Rockville MD: Substance Abuse and Mental Health Administration, 2011. (22 refs.)

This report describes the origins and structure of the Drug Abuse Warning Network (DAWN), and the 12 metropolitan areas included in the study.. Information collected by DAWN includes types of cases, demographic characteristics, drug class(es), and disposition of the emergency room visit.

Public Domain

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The DAWN Report: Emergency Department Visits Involving Underage Alcohol Use in Combination with Other Drugs. (January 13, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (6 refs.)

The National Survey on Drug Use and Health (NSDUH), show widespread use of alcohol among adolescents and young adults under the legal drinking age of 21. For example, 2009 NSDUH data showed that more than one half (52.2 percent) of young people aged 12 to 20 reported that they had consumed at least one alcoholic drink in their lifetime, 44.6 percent had consumed alcohol in the past year, 27.2% had consumed alcohol in the past month, and 18.1 percent reported binge alcohol use (i.e., drank five or more drinks on the same occasion on at least 1 day in the 30 days prior to the survey). In addition, 17.5 percent of underage drinkers reported that they had used illicit drugs within 2 hours of their last drinking occasion, a rate more than 3 times as high as that of drinkers aged 21 or older (5.0%). Among underage drinkers who reported illicit drug use within 2 hours of their last drinking occasion, marijuana was the most commonly reported drug used (16.9%). The use of alcohol in combination with illicit and other drugs is of particular concern given the potentially dangerous additive or interactive effects that may result. Research shows that the use of alcohol in combination with other drugs is associated with a variety of negative outcomes such as overdose, suicide, risky sexual behavior, alcohol dependence, depression, and social consequences such as legal, work, and health problems. Of the estimated 188,981 alcohol-related emergency department (ED) visits made by patients aged 12 to 20 in 2008, 70.0% involved alcohol only, and 30.0% involved alcohol in combination with other drugs. Illicit drug use was indicated in more than two thirds (68.4%), and pharmaceutical drugs were involved in more than one half (55.1 percent) of ED visits involving alcohol in combination with other drugs among patients aged 12 to 20. Among adolescents aged 12 to 17, 3 in 10 (30.2%) alcohol-related ED visits made by females involved other drugs, whereas more than 2 in 10 (22.9%) of such visits were made by males; among young adults aged 18 to 20, about one third of such visits made by both males (31.9 percent) and females (33.3 percent) involved other drugs. Of patients aged 12 to 20 who made alcohol-related ED visits involving other drugs, nearly two thirds (64.5%) had no evidence of follow-up care.

Public Domain

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The DAWN Report: Emergency Department Visits Involving Ecstasy. (March 24, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (4 refs.)

The number of drug-related emergency department (ED) visits involving 3,4-methylenedioxymeth-amphetamine (MDMA), commonly known as "Ecstasy," increased significantly from 10,220 visits in 2004 to 17,865 visits in 2008, representing a 74.8%increase. Most ED visits involving Ecstasy in 2008 (69.3 percent) were made by patients aged 18 to 29. An estimated 77.8 percent of these ED visits involved Ecstasy in combination with alcohol or other drugs (including pharmaceuticals or illicit drugs); in fact, 31.3% involved one other drug, 15.0% involved two other drugs, 14.0 percent involved three other drugs, and 17.5 percent involved four or more other drugs. Ecstasy-related ED visits among patients aged 21 or older were more likely than those made by patients aged 20 or younger also to involve alcohol (50.1 vs. 20.4%) or cocaine (43.4 vs. 14.7%). Because it provides psychedelic and stimulant side effects, Ecstasy is associated with dynamic social environments, such as parties or raves, where there is loud music and dancing. Yet the benign nicknames and the lively social environments in which the drug often is used belie the serious health and mental consequences that can result from casual to heavy Ecstasy use. Aside from addiction, Ecstasy use can cause anxiety, agitation, recklessness, increased blood pressure, dehydration, heat stroke, muscle cramping, blurred vision, hyperthermia, heart failure, and kidney failure.2 The social and environmental contexts in which Ecstasy often is used-prolonged vigorous activity in warm environments, such as dancing at crowded parties-can amplify associated cardiovascular health risks.3 Because it also compromises metabolic functioning, Ecstasy taken in combination with other drugs may place users at increased risk for additional and life-threatening drug interactions.3

Public Domain

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The DAWN Report: Emergency Department Visits Involving Adverse Reactions to Medications among Older Adults. (February 24, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (7 refs.)

In 2008, an estimated 1,111,686 emergency department (ED) visits were made by adults aged 50 or older for adverse reactions to pharmaceuticals or other types of medications. More than half of these visits (61.5%) were made by adults aged 65 or older. Central nervous system (CNS) drugs (e.g., pain relievers and drugs used to treat anxiety and insomnia) were involved in almost one fourth (24.3%) of ED visits for adverse drug reactions among older adults. Nearly two thirds of older adults who visited the ED for adverse drug reactions were treated and released (64.2 percent), and nearly one third were admitted to the hospital (32.9%). As adults age, they experience increased health problems, have more medical visits, and take an increasing number of medications (pharmaceuticals and over-the-counter [OTC] medications) compared with younger persons. Because of physiological changes (e.g., decreased kidney and liver function) and because adults aged 50 or older (hereafter referred to as older adults) often take multiple medications, they are at higher risk of experiencing an adverse reaction

Public Domain

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The DAWN Report: Drug-Related Emergency Department Visits Attributed to Intentional Poisoning. (November 3, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (7 refs.)

Based on information from the DAWN network, in 2009, there were an estimated 14,720 emergency department (ED) visits attributed to intentional drug poisoning. Three quarters (73%) of drug-related ED visits attributed to intentional poisoning were made by patients aged 21 or older. Females accounted for nearly two thirds of drug-related ED visits attributed to intentional poisoning (63%). Approximately 60 percent of these ED visits in 2009 involved unidentified drugs, and a similar percentage involved alcohol in combination with other drugs. Detecting intentional poisoning is difficult because a victim often is unable to recall what took place, and the intent of the suspect cannot be confirmed. Research has shown that victims often have been drinking alcohol, which impairs their ability to recognize dangerous situations and suspicious behavior of other individuals. Depending on the drug or combination of drugs taken, victims may experience drowsiness and loss of consciousness, leaving them vulnerable to crimes such as robbery, physical assault, or sexual assault. In 2009, poison control centers in the United States received more than 7,700 reports of intentional poisoning by another person, and in 2007, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control reported 85 homicide poisoning deaths. While information for other drug-facilitated crimes is sparse, it has been estimated that approximately 3 million American women have experienced drug-facilitated rape in their lifetime.

Public Domain

Chavira C; Bazargan-Hejazi S; Lin J; del Pino HE; Bazargan M. Type of alcohol drink and exposure to violence: An emergency department study. Journal of Community Health 36(4): 597-604, 2011. (27 refs.)

We compared the prevalence of exposure to violence across different types of alcohol consumed and the association between the type of alcohol consumed and exposure to violence. A cross-sectional analysis of data collected from a sample of 295 Emergency Department (ED) patients identified as having an alcohol problem. Outcome measure include exposure to violence, and the main study predictor was "type of alcoholic drink" including: malt liquor beer (MLB), regular beer, wine cooler, wine, fortified wine or hard liquor. Using logistic regression analysis, ED patients who drank MLB in combination with other types of alcohol increased their odds of being both threatened and physically attacked by 8.5 compared to ED patients who drank other types of alcohol. Being female increased the odds of being both threatened and physically attacked by 2.5 and using illicit drugs increased the odds by 3.8. Analysis of covariance and estimated marginal means revealed that ED patients who only drank MLB had a higher exposure to violence compared to non-MLB drinkers, and that female illicit drug users who drank MLB in combination with other types of alcohol had the highest exposure to violence. MLB was identified as a predictor of the amount of exposure to violence and in particular, that the use of malt liquor beer in combination with other types of alcohol increased the risk of being both threatened and physically attacked. Implications for ED and community interventions are suggested.

Chen ICJ; Hung DZ; Hsu CH; Wu ML; Deng JF; Chang CY et al. Drug abuse-related accidents leading to emergency department visits at two medical centers. Journal of the Chinese Medical Association 75(5): 234-239, 2012. (14 refs.)

Background: Drug abuse is becoming more prevalent in Taiwan, as evidenced by increasing reports of drug trafficking and drug abuse-related criminal activity, and the wide use of more contemporary illicit drugs. Consequently, drug abuse-related accidents are also expected to occur with greater frequency. However, no study has yet specifically evaluated the prevalence, pattern, and outcomes of drug abuse-related accidents among patients visiting emergency departments (EDs) in Taiwan. Methods: We conducted an ambidirectional study with patients who visited the EDs of Taipei Veterans General Hospital (TVGH) and China Medical University Hospital (CMUH) due to drug abuse-related accidents from January 2007 through September 2009. Information on the patients' baseline characteristics and clinical outcomes was collected and analyzed. Results: During the study period, a total of 166 patients visited the EDs of one of the two study hospitals due to drug abuse-related accidents. This yielded a prevalence of drug abuse of 0.1% among all patients visiting the ED due to accident and/or trauma. Fifty-six out of the 166 patients visited the ED at TVGH, most patients being between 21 and 40 years old. Opioids (41.1%) were the drugs most commonly abused by the patients, followed by benzodiazepines (32.1%). More than two-thirds of the patients (n = 38, 67.9%) required hospitalization, and three patients died (5.4%). In contrast, 110 patients with drug abuse-related accidents visited the ED at CMUH during the study period. Most of these subjects had abused benzodiazepines (69.1%), were between 21 and 40 years old, and were female. Fewer than one-fifth of the patients (n = 19, 17.3%) required hospitalization, with no deaths reported. There were significant between-hospital differences in terms of patient gender, drugs of choice, injury mechanisms, method and time of the ED visit, triage levels, and need for hospitalization. Conclusion: Although the prevalence of drug abuse-related accidents was low, and only three patient deaths were reported in this study, many patients presented to the EDs with severe effects and later required hospitalization. Better and timely management of such patients will help to minimize the adverse health impacts associated with drug abuse. Governmental agencies and all healthcare professionals should also work together to fight against the surging trend of drug abuse in Taiwan.

Cherpitel CJ; Ye Y. Trends in alcohol- and drug-related emergency department and primary care visits: Data from four U.S. national surveys (1995-2010). Journal of Studies on Alcohol and Drugs 73(3): 454-458, 2012. (30 refs.)

Objective: The purpose of this study was to update trends in alcohol- and drug-related emergency department and primary care visits over the last 15 years in the United States. Method: A trend analysis was conducted on substance-related health services visits, based on self-reported alcohol or other drug use within 6 hours before an injury and/or illness event, from four National Alcohol Surveys: 1995, 2000, 2005, and 2010. Results: A significant upward trend was found from 1995 to 2010 in alcohol-related emergency department visits but not in alcohol-related primary care visits. The odds of an alcohol-related emergency department visit doubled between 1995 and 2010 (odds ratio = 2.36). No significant trend was found in either drug-related emergency department or drug-related primary care visits between 1995 and 2010. Conclusions: These data suggest that alcohol-related emergency department visits have increased significantly over the past 15 years, whereas drug-related emergency department visits may have stabilized. These findings underscore the opportunity provided by the emergency department for screening and brief intervention for alcohol-related problems and suggest that Healthy People 2010 objectives calling for a reduction in substance-related emergency department visits were not realized. Thus, it might be prudent to adjust Healthy People 2020 objectives accordingly.

Cleary K; Levine DA; Hoffman RS. Adolescents and young adults presenting to the emergency department intoxicated from a caffeinated alcoholic beverage: A case series. Annals of Emergency Medicine 59(1): 67-69, 2012. (15 refs.)

We describe a case series of emergency department (ED) visits for intoxication related to the use of the caffeinated alcoholic beverage Four Loko. Medical records from the 4-month period July to November 2010 were hand searched for key words such as "intoxicated," "caffeinated," "Four Loko," "alcohol," and "EtOH." Patients were included if they were younger than 25 years. Eleven cases were included. Eight (72.7%) patients presented during October 2010. The median age was 16.4 years; 90.9% were under the legal drinking age of 21 years. Seven (63.6 %) were male patients. All arrived by emergency medical services (EMS). Four patients (36.3%) were found in high-risk settings, with altered mental status on subway tracks, in public buildings, or parks after dark. Two patients had blood alcohol concentrations greater than 200 mg/dL. Six patients (54.5%) had emesis. Two patients (18.2%) were admitted to hospital, 1 each because of seizures and persistent tachycardia. Patients intoxicated with Four Loko were younger than the legal drinking age, found in high-risk situations, and often admitted to the hospital. Many of these patients used EMS and resources in the ED for alleviation of adverse effects of Four Loko.

Cunningham RM; Walton MA; Harrison SR; Resko SM; Stanley R; Zimmerman M et al. Past-year intentional and unintentional injury among teens treated in an inner-city emergency department. Journal of Emergency Medicine 41(4): 418-426, 2011. (45 refs.)

An inner-city emergency department (ED) visit provides an opportunity for contact with high-risk adolescents to promote injury prevention. Objectives: To identify the prevalence of injuries sustained over the past year by teens presenting to an inner-city ED, and to identify factors associated with recent injury to inform future ED-based injury prevention initiatives. Methods: Over 1 year, 7 days a week, from 1:00-11:00 p.m., patients aged 14-18 years presenting to the ED participated in a survey regarding past-year risk behaviors and injuries. Results: Of the entire group of teens presenting to the ED (n = 1128) who completed the survey (83.8% response rate), 46% were male, and 58% were African-American. Past-year injuries were reported by 768 (68.1%) of the teens; 475 (61.8%) of those reported an unintentional injury and 293 (38.1%) reported an intentional injury. One-third of all youth seeking care reported a past-year sports-related injury (34.5%) or an injury related to driving or riding in a car (12.3%), and 8.2% reported a gun-related injury. Logistic regression found that binge drinking (adjusted odds ratio [AOR] 1.95) and illicit weapon carrying (AOR 2.31) predicted a past-year intentional injury. African-American youth (AOR 0.56) and those receiving public assistance (AOR 0.73) were less likely to report past-year unintentional injuries. Conclusions: Adolescents seeking care in an inner-city ED, regardless of the reason for seeking care, report an elevated prevalence of recent injury, including violence. Future injury screening and prevention efforts should consider universal screening of all youth seeking ED care.

Cusack L; de Crespigny C; Athanasos P. Heatwaves and their impact on people with alcohol, drug and mental health conditions: A discussion paper on clinical practice considerations. Journal of Advanced Nursing 67(4): 915-922, 2011. (28 refs.)

Aim. This article discusses the clinical implications of adverse health outcomes derived during heatwaves for people with mental health disorders, substance misuse and those taking prescribed medications such as lithium, various neuroleptic and anticholinergic drugs. Background. With climate change it is predicted that the incidence of prolonged periods of extreme heat will increase. Specific adverse health outcomes associated with high environmental temperatures include heat stroke and heat exhaustion. Those at increased risk for heat-related mortality are those with chronic health conditions, including those with mental health disorders and substance misuse. Data sources. Sources of evidence included and 'grey' literature published between 1985 and 2010, such as key texts, empirical research, public policies, training manuals and community information sheets on heat waves. Discussion. Current clinical practice and clinical impact of heatwaves on those people with comorbidity is explored. This includes the physiological components of heat stress, heat regulation, and the impact of alcohol and other drugs; and, ramifications and professional practice issues for those with mental health conditions and those requiring mental health medications. Implications for nursing. Client education covering modification of the environment and the use of client heat safety action plans. Secure, accessible stores of prescribed medication are recommended and emergency substance withdrawal kits could be made available. Conclusion. All nurses have a responsibility to increase the capability and resilience of their clients to manage their chronic health needs during a heatwave. At these times nurses need to give extra monitoring and assistance when clients lack the capacity or resources to protect themselves.

Daugherty LE. Extracorporeal membrane oxygenation as rescue therapy for methadone-induced pulmonary edema. Pediatric Emergency Care 27(7): 633-634, 2011. (14 refs.)

Opioid-induced pulmonary edema has been previously reported, but its mechanism remains unclear. The use of extracorporeal membrane oxygenation as rescue therapy for methadone-induced pulmonary edema has not been reported in the literature. We describe 2 cases of methadone ingestion complicated by pulmonary edema, acute respiratory distress syndrome, and circulatory failure successfully managed with venoarterial extracorporeal membrane oxygenation.

Delgado MK; Acosta CD; Ginde AA; Wang NE; Strehlow MC; Khandwala YS et al. National survey of preventive health services in US emergency departments. Annals of Emergency Medicine 57(2): 104-108, 2011. (11 refs.)

Study objective: We describe the availability of preventive health services in US emergency departments (EDs), as well as ED directors' preferred service and perceptions of barriers to offering preventive services. Methods: Using the 2007 National Emergency Department Inventory (NEDI)-USA, we randomly sampled 350 (7%) of 4,874 EDs. We surveyed directors of these EDs to determine the availability of (1) screening and referral programs for alcohol, tobacco, geriatric falls, intimate partner violence, HIV, diabetes, and hypertension; (2) vaccination programs for influenza and pneumococcus; and (3) linkage programs to primary care and health insurance. ED directors were asked to select the service they would most like to implement and to rate 5 potential barriers to offering preventive services. Results: Two hundred seventy-seven EDs (80%) responded across 46 states. Availability of services ranged from 66% for intimate partner violence screening to 19% for HIV screening. ED directors wanted to implement primary care linkage most (17%) and HIV screening least (2%). ED directors "agreed/strongly agreed" that the following are barriers to ED preventive care: cost (74%), increased patient length of stay (64%), lack of follow-up (60%), resource shifting leading to worse patient outcomes (53%), and philosophical opposition (27%). Conclusion: Most US EDs offer preventive services, but availability and ED director preference for type of service vary greatly. The majority of EDs do not routinely offer Centers for Disease Control and Prevention recommended HIV screening. Most ED directors are not philosophically opposed to offering preventive services but are concerned with added costs, effects on ED operations, and potential lack of follow-up.

Dicker RA; Mah J; Lopez D; Tran C; Reidy R; Moore M et al. Screening for mental illness in a trauma center: Rooting out a risk factor for unintentional injury. Journal of Trauma, Injury, Infection and Critical Care 70(6): 1337-1344, 2011. (20 refs.)

Background: Injury prevention and screening efforts have long targeted risk factors for injury recurrence. In a retrospective study, our group found that mental illness is an independent risk factor for unintentional injury and reinjury. The purpose of this study was to administer a standard validated screening instrument and psychosocial needs assessment to admitted patients who suffer unintentional injury. We aimed to prospectively measure the prevalence of mental illness. We hypothesize that systematic screening for psychiatric disorders in trauma patients is feasible and identifies people with preexisting mental illness as a high-risk group for unintentional injury. Methods: In this prospective study, we recruited patients admitted to our Level I trauma center for unintentional injury for a period of 18 months. A bedside structured interview, including the Mini International Neuropsychiatric Interview, and a needs assessment were performed by lay research personnel trained by faculty from the Department of Psychiatry. The validated needs assessment questions were from the Camberwell Assessment of Need Short Appraisal Schedule instrument. Psychiatric screening and needs assessment results, as well as demographic characteristics are reported as descriptive statistics. Results: A total of 1,829 people were screened during the study period. Of the 854 eligible people, 348 were able to be approached by researchers before discharge with a positive response rate of 63% (N = 219 enrolled). Interviews took 35 minutes +/- 12 minutes. Chi-squared analysis revealed no difference in mechanism in those with mental illness versus no mental illness. Men were significantly more likely to be found to have a mental health disorder but when substance abuse was excluded, no difference was found. Four-way diagnostic grouping revealed the prevalence of mental illness detected. Conclusions: This inpatient pilot screening program prospectively identified preexisting mental illness as a risk factor for unintentional injury. Implementation of validated psychosocial and mental health screening instruments is feasible and efficient in the acute trauma setting. Administration of a validated mental health screening instrument can be achieved by training college-level research assistants. This system of screening can lead to identification and treatment of mental illness as a strategy for unintentional injury prevention.

Doupe MB; Palatnick W; Day S; Chateau D; Soodeen RA; Burchill C et al. Frequent users of emergency departments: Developing standard definitions and defining prominent risk factors. Annals of Emergency Medicine 60(1): 24-32, 2012. (57 refs.)

Study objective: We identify factors that define frequent and highly frequent emergency department (ED) users. Methods: Administrative health care records were used to define less frequent (1 to 6 visits), frequent (7 to 17 visits), and highly frequent (>= 18 visits) ED users. Analyses were conducted to determine the most unique demographic, disease, and health care use features of these groups. Results: Frequent users composed 9.9% of all ED visits, whereas highly frequent users composed 3.6% of visits. Compared with less frequent users, frequent users were defined most strongly by their substance abuse challenges and by their many visits to primary care and specialist physicians. Substance abuse also distinguished highly frequent from frequent ED users strongly; 67.3% versus 35.9% of these patient groups were substance abusers, respectively. Also, 70% of highly frequent versus only 17.8% of frequent users had a long history of frequent ED use. Last, highly frequent users did not use other health care services proportionally more than their frequent user counterparts, suggesting that these former patients use EDs as a main source of care. Conclusion: This research develops objective thresholds of frequent and highly frequent ED use. Although substance abuse is prominent in both groups, only highly frequent users seem to visit EDs in place of other health care services. Future analyses can investigate these patterns of health care use more closely, including how timely access to primary care affects ED use. Cluster analysis also has value for defining frequent user subgroups who may benefit from different yet equally effective treatment options.

Drake RE; Caton CLM; Xie HY; Hsu E; Gorroochurn P; Samet S et al. A prospective 2-year study of emergency department patients with early-phase primary psychosis or substance-induced psychosis. American Journal of Psychiatry 168(7): 742-748, 2011. (32 refs.)

Objective: The authors examined treatment utilization and outcomes over 2 years among patients admitted to emergency departments with early-phase primary or substance-induced psychosis. The main hypothesis was that patients with substance-induced psychosis would have a more benign course of illness than those with primary psychosis. Method: Using a prospective naturalistic cohort study design, the authors compared 217 patients with early-phase primary psychosis plus substance use and 134 patients with early-phase substance-induced psychosis who presented to psychiatric emergency departments at hospitals in Upper Manhattan. Assessments at baseline and at 6, 12, 18, and 24 months included psychiatric diagnoses, service use, and institutional outcomes using the Psychiatric Research Interview for Substance and Mental Disorders; psychiatric symptoms using the Positive and Negative Syndrome Scale; social, vocational, and family functioning using the World Health Organization Psychiatric Disability Assessment Schedule; and life satisfaction using the Quality of Life Interview. Longitudinal analyses were conducted using generalized estimating equations. Results: Participants with primary psychosis were more likely to receive antipsychotic and mood-stabilizing medications, undergo hospitalizations, and have outpatient psychiatric visits; those with substance-induced psychosis were more likely to receive addiction treatments. Only a minority of each group received minimally adequate treatments. Both groups improved significantly over time on substance dependence, psychotic symptoms, homelessness, and psychosocial outcomes, and few group-by-time interactions emerged. Conclusions: Patients presenting to Upper Manhattan emergency departments with either early-phase primary psychosis or substance-induced psychosis improved steadily over 2 years despite minimal use of mental health and substance abuse services.

Duineveld C; Vroegop M; Schouren L; Hoedemaekers A; Schouten J; Moret-Hartman M et al. Acute intoxications: Differences in management between six Dutch hospitals. Clinical Toxicology 50(2): 120-128, 2012. (27 refs.)

Context. Acute intoxications are frequently seen in Dutch hospitals. Based on single-centre studies and the fact that there are no clear guidelines, we hypothesised that hospital admission of acute intoxications may vary. Furthermore, decontamination treatment of poisonings may differ between hospitals, as earlier studies showed that adherence to international guidelines concerning decontamination may be poor. Objective. We aim to identify possible variations in Dutch hospital admission and decontamination treatment of patients with acute intoxications. Materials and methods. Data on acute intoxications was retrospectively collected from patient records from the emergency departments of six Dutch hospitals. All patients older than 14 years who presented between 1 January 2008 and 31 December 2008 were included in the study. Results. The percentage of suicide attempts differed significantly between the hospitals (25-73%, p < 0.0001) as equally the percentage of intoxications with drugs of abuse (18-61%, p < 0.0001). Marked differences in admission rates were found (27-78%, p < 0.0001) and these differences remained even when intoxications because of suicide attempts and drugs of abuse were analysed separately (admission rate of 52-87%, p < 0.0001 and 8-71%, p < 0.0001 respectively). Reported consultation with the National Poisons Information Centre differed between hospitals (range 0% to 80-100%). No statistical differences were found between hospitals for the use of activated charcoal (16.1-42.5%, p = 0.037). Gastric lavage was used infrequently in all hospitals. (6.6-16.7%, p = 0.614). Discussion and conclusion. The admission rate of patients with an acute intoxication varies considerably, especially in the case of intoxications with drugs of abuse. Consultations with the National Poisons Information Centre differed between the six hospitals. Rates of decontamination did not vary, which may indicate adherence to guidelines by the American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. National guidelines or admission algorithms may reduce variations in poisoning management and make the care for these patients more efficient.

Egan DJ; Pare JR. Clinical pathologic conference: A 65-year-old male with left-sided chest pain. A case of an unexpected occupational hazard. Academic Emergency Medicine 19(2): e1-e6, 2012. (36 refs.)

The authors present a case of a 65-year-old male who presented four times to the emergency department (ED) with left-sided chest pain. On the first three visits, the patient was admitted with a different diagnosis related to his chest pain. On the final visit, an abnormality on an imaging study performed in the ED led to the ultimate diagnostic test revealing the cause of the patient's symptoms. The patient's clinical presentation and ultimate clinical course are summarized, and a discussion of the differential diagnoses of his condition is presented.

Fortney JC; Tripathi SP; Walton MA; Cunningham RM; Booth BM. Patterns of substance abuse treatment seeking following cocaine-related emergency department visits. Journal of Behavioral Health Services & Research 38(2): 221-233, 2011. (45 refs.)

Chest pain is the most common medical complaint among cocaine-using emergency department (ED) patients. Correlates of substance abuse treatment seeking were examined using 3-month post-discharge surveys from 170 ED patients admitted with cocaine-related chest pain. Four treatment categories were specified as the dependent variable in an ordered logistic regression: no treatment (74.7%), informal treatment only (7.1%), formal treatment only (5.9%), and both formal and informal treatment (12.4%). The following variables were found to be positively associated with a higher treatment category: frequency of cocaine use (OR = 1.07, CI95 = 1.01-1.15, p = 0.03), global severity index (OR = 2.26, CI95 = 1.04-4.90, p = 0.04), number of endorsed stigma barriers (OR = 4.40, CI95 = 1.41-13.78, p = 0.01), interpersonal consequences (OR = 1.41, CI95 = 1.01-1.88, p = 0.02), and pre-baseline informal treatment (OR = 6.69, CI95 = 1.58-28.36, p = 0.01). Physical consequences were found to be negatively associated with a higher treatment category (OR = 0.63, CI95 = 0.47-0.85, p < 0.01). ED visits for cocaine-related chest pain represent missed opportunities to link patients to substance abuse treatment, and interventions are needed to motivate patients to seek care.

French MT; Fang H; Balsa AI. Longitudinal analysis of changes in illicit drug use and health services utilization. Health Services Research 46(3): 877- 899, 2011. (44 refs.)

Objective: To analyze the relationships between illicit drug use and three types of health services utilization: emergency room utilization, hospitalization, and medical attention required due to injury(s). Data: Waves 1 and 2 (11,253 males and 13,059 females) from the National Epidemiology Survey on Alcohol and Related Conditions (NESARC). Study Design: We derive benchmark estimates by employing standard cross-sectional data models to pooled waves of NESARC data. To control for potential bias due to time-invariant unobserved individual heterogeneity, we reestimate the relationships with fixed-effects models. Principal Findings: The cross-sectional data models suggest that illicit drug use is positively and significantly related to health services utilization in almost all specifications. Conversely, the only significant (p <.05) relationships in the fixed-effects models are the odds of receiving medical attention for an injury and the number of injuries requiring medical attention for men, and the number of times hospitalized for men and women. Conclusions: Failing to control for time-invariant individual heterogeneity could lead to biased coefficients when estimating the effects of illicit drug use on health services utilization. Moreover, it is important to distinguish between types of drug user (casual versus heavy) and estimate gender-specific models.

Friend K; Milone MC; Perrone J. Hyponatremia associated with levamisole-adulterated cocaine use in emergency department patients. Annals of Emergency Medicine 60(1): 94-96, 2012. (6 refs.)

An increasing percentage of US cocaine has been adulterated with levamisole, an immunomodulator associated with agranulocytosis. We describe 3 emergency department patients with hyponatremia and cocaine use. [NB. Hyponatremia is low levels of sodium in the blood.] Despite extensive evaluation, the cause of the hyponatremia was not elucidated but resolved during hospitalization. Because hyponatremia has not previously been associated with cocaine, we sought to uncover a plausible explanation that might be contributing to this new finding. Levamisole was detected in all 3 patients. Although we are unable to confirm causality, we propose that levamisole-adulterated cocaine may have contributed to the hyponatremia described in these patients.

Fulde G; Preisz P. Managing aggressive and violent patients. Australian Prescriber 34(4): 115-118, 2011. (8 refs.)

All healthcare workers, especially general practitioners and staff in emergency departments, are likely to encounter aggression and violence. This behaviour may be caused by a medical illness, a psychiatric illness or drug intoxication or withdrawal. These problems can occur in combination. It is important that a diagnosis is made, but in some cases the patient may need sedation before they can be examined. If non-drug management, such as de-escalation techniques, does not work, a benzodiazepine or antipsychotic can be considered. It is essential that sedated patients are monitored for signs of oversedation. Practice design and policies as well as staff training can help to reduce the risk of violence.

Galicia M; Nogue S; Casanas X; Iglesias ML; Puiguriguer J; Supervia A et al. Multicenter assessment of the revisit risk for a further drug-related problem in the emergency department in cocaine users (MARRIED-cocaine study). Clinical Toxicology 50(3): 176-182, 2012. (30 refs.)

Introduction and objectives. Emergency departments (EDs) in Spanish hospitals daily attend a large number of patients for adverse reactions or clinical complications resulting from cocaine use. After discharge, some of these patients revisit the ED for the same reason within a year. The objective of the present study was to quantify the rate of such revisits and identify the factors associated with them. Method. We performed a retrospective, multicenter study with cohort follow-up and without a control group, conducted in the EDs of six Spanish hospitals during 12 months (January-December 2009). We included all ED patients attended for cocaine-related symptoms who reported recent cocaine use and those with cocaine-positive urine analysis by immunoassay without declared consumption. Twelve independent variables assessed for each hospital ED were collected: sex, age, place of consumption, month, day, and time of consumption, mode of arrival at the ED, discharge diagnosis, psychiatric assessment on the ED episode, concomitant drugs, destination on discharge, and history of previous ED visits related with drug use and alcohol use. The dependent variable was a subsequent visit to the ED associated with drug use, identified using the computerized hospital admissions system. Results. The study included 807 patients, of whom 6.7% revisited the ED within 30 days, 11.9% within 3 months and 18.9% within 1 year. The variables significantly associated with ED revisits were: presence of clinical manifestations directly related to cocaine (p < 0.05), ED attendance on a working day (p < 0.05), history of ED visits related with the consumption of alcohol (p < 0.001) or drugs (p < 0.001), and the need for urgent consultation with a psychiatrist (p < 0.001), although only the last four were independent predictors in multivariate analysis. We derived a score based on these variables to predict risk of revisits (MARRIED-score, ranging from 0 to 400 points), which had a reasonably good predictive value for revisit (area under ROC of 0.75; 95% CI 0.71-0.79).

Gallagher R. Addiction and emergency. (Chapter 23). IN: Brizer D; Castandea R, eds. Clinical Addiction Psychiatry. New York: Cambridge University Press, 2011

This book is described as an anthology of essays setting forth the most current and authoritative information on addiction theory, practice and research. Each chapter is authored by a recognized authority in the field. The volume covers diverse material, from the environment, to genetics, culture and spirituality, treatment and pharmacology. The book, with 24 essays, is organized in three parts. This chapter is part of Part III, a section with the title "Praxis" The chapters in this section central issues in clinical practices. This chapter reviews the medical emergencies associated with substance use. Other chapters in this section deal with methadone-maintenance; EEG neurofeedback; pain management in those with addictions; psychotherapy in addiction treatment; the new pharmacotherapies for alcohol dependence; addiction and emergency care; and ear acupuncture in addiction treatment.

Green SM; Roback MG; Kennedy RM; Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. (review). Annals of Emergency Medicine 57(5): 449- 461, 2011. (112 refs.)

We update an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department procedural sedation and analgesia. Substantial new research warrants revision of the widely disseminated 2004 guideline, particularly with respect to contraindications, age recommendations, potential neurotoxicity, and the role of coadministered anticholinergics and benzodiazepines. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for ketamine dissociative sedation.

Halpern P; Moskovich J; Avrahami B; Bentur Y; Soffer D; Peleg K. Morbidity associated with MDMA (ecstasy) abuse: A survey of emergency department admissions. Human & Experimental Toxicology 30(4): 259-266, 2011. (35 refs.)

Methods: We conducted a prospective, representative-sample nationwide study on morbidity related to 3,4, methylenedioxymethamphetamine (MDMA; 'ecstasy') as determined from admissions to 5 geographically representative emergency departments (EDs) and from data from the poison information center (PIC). MDMA-related ED admissions were analyzed over a 7-month period and the records of all PIC calls were reviewed. Results: There were 52 (age 15-44 years, 32 males) ecstasy-related ED admissions during the study period. Most (68%) admissions presented to the ED at night, 52% on weekends and 44% consumed the drug at clubs and parties. Forty-six percent of the patients took between 1/2 to 3 tablets and 29 patients (56%) had taken ecstasy before. Twenty-two subjects (42%) reported poly-drug use. Fifteen subjects (29%) required hospitalization, six of them (11%) to the intensive care unit. The most common manifestations were restlessness, agitation, disorientation, shaking, high blood pressure, headache and loss of consciousness. More serious complications were hyperthermia, hyponatremia, rhabdomyolysis, brain edema and coma. Conclusion: The image of ecstasy as a safe party drug is spurious. The results of this study confirm that the drug bears real danger of physical harm and of behavioral, psychological and psychiatric disturbances.

Hansagi H; Engdahl B; Romelsjo A. Predictors of repeated emergency department visits among persons treated for addiction. European Addiction Research 18(2): 47-53, 2012. (33 refs.)

Background/Aims: To determine whether frequent emergency department (ED) users who enter specialized treatment programs for alcohol and/or drug problems have any characteristics that predict their future ED use. Methods: Adult patients (783 alcohol users, 405 illicit drug users) were interviewed. Data from the medical database on utilization of ED and the emergency departments' specific units for addictive diseases (EDAD) 12 months before and 12 months after the interview were linked with patient characteristics in logistic regression models. Results: Among alcohol users, prior ED/EDAD visits predicted repeat future visits to these sites (OR 11.6; 95% CI 6.5-20.5). Prior inpatient hospital care with addiction diagnosis was a predictor of future multiple visits to the EDAD only (OR 3.1; 95% CI 1.5-6.5). Among drug users, predictors of future ED/EDAD visits were use of heroin (OR 2.7; 95% CI 1.4-5.4) and prior ED/EDAD visits (OR 27.3; 95% CI 12.7-58.4). Drug users' EDAD utilization was also predicted by inpatient hospital care with addiction diagnosis. Conclusion: The strongest predictive factors of visiting ED repeatedly were previous repeat emergency care use and hospitalization with addiction diagnosis. Entering regular addiction treatment does not appear to alter the pattern of ED utilization.

Havard A; Shakeshaft AP; Conigrave KM. Prevalence and characteristics of patients with risky alcohol consumption presenting to emergency departments in rural Australia. Emergency Medicine Australasia 24(3): 266-276, 2012. (38 refs.)

Objective: This study measures the prevalence of problematic alcohol consumption in patients of EDs in rural areas of Australia, relative to the general population in the same rural communities. It also identifies the characteristics associated with risky drinking in rural ED patients. Methods: Surveys containing the Alcohol Use Disorders Identification Test (AUDIT) and questions corresponding to the 2001 Australian Alcohol Guidelines were completed by 1056 patients presenting to five EDs in rural areas of New South Wales, and 756 residents of the same five communities. Results: Relative to the general community, ED patients were statistically significantly more likely to engage in risky alcohol consumption according to the AUDIT (39% vs 20%), alcohol consumption posing a high risk of short-term harm (26% vs 18%) and alcohol consumption posing a high risk of long-term harm (7% vs 3%). Although being aged under 40 years of age, being unmarried, not completing school and being assigned less urgent triage categories were associated with risky alcohol use among ED patients, rates of risky consumption were high across all patient subgroups. Conclusions: Risky drinking, across a number of measures, is overrepresented in patients of rural Australian EDs relative to the general community, and this type of consumption is not limited to certain subgroups of patients. There is a need for interventions that address both heavy single occasion drinking and excessive regular consumption in patients of rural Australian EDs, with universal interventions recommended rather than targeted programmes.

Havard A; Shakeshaft AP; Conigrave KM; Doran CM. Randomized controlled trial of mailed personalized feedback for problem drinkers in the emergency department: The short-term impact. Alcoholism: Clinical and Experimental Research 36(3): 523-531, 2012. (73 refs.)

Background: Evidence exists for the efficacy of emergency department (ED)-based brief alcohol interventions, but attempts to incorporate face-to-face interventions into routine ED practice have been hampered by time, financial, and attitudinal constraints. Mailed personalized feedback, which is likely to be more feasible, has been associated with reduced alcohol consumption in other settings, but its cost-effectiveness in the ED has not been examined. Methods: The intervention was evaluated with a randomized controlled trial of patients presenting to 5 rural EDs in New South Wales, Australia. Patients aged 14 years and older were screened using the Alcohol Use Disorders Identification Test, and those scoring 8 or more were randomly allocated to the intervention or control group. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback. Results: Two hundred and forty-four (80%) participants were successfully followed up at 6 weeks. A significant effect of the mailed feedback was observed only in patients with an alcohol-involved ED presentation. Among this subgroup of participants, those in the intervention group consumed 12.2 fewer drinks per week than the control group after controlling for baseline consumption and other covariates (effect size d = 0.59). The intervention was associated with an average cost of Australian $ 5.83 per patient, and among participants with an alcohol-involved ED presentation, an incremental cost-effectiveness ratio of 0.48. Conclusions: Mailed personalized feedback is efficacious in reducing quantity/frequency of alcohol consumption among patients with alcohol-involved ED presentations. Mailed feedback has high cost-efficacy and a low absolute cost, making it a promising candidate for integration into ED care.

Kasick DP; McKnight CA; Klisovic E. "Bath salt" ingestion leading to severe intoxication delirium: Two cases and a brief review of the emergence of mephedrone use. American Journal of Drug and Alcohol Abuse 38(2): 176-180, 2012. (17 refs.)

Background: Recreational use of designer substances containing synthetic cathinones such as mephedrone, commonly sold as "bath salts," has recently been increasing in the United States. "Bath salt" ingestion can generate an intense stimulant toxidrome and has been associated with significant morbidity. Objectives: The authors seek to alert clinicians to the potential for profound delirium, psychosis, and other medical and behavioral sequelae of "bath salt" use. Methods: Case series. Results: We describe our recent experience with two highly agitated and delirious patients following "bath salt" ingestion and offer a brief review of the emergence of this phenomenon. Conclusions: Challenges and strategies surrounding diagnosis and treatment are described, which may be useful as "bath salt" use becomes more widespread. Scientific Significance: As an emerging trend, bath salt intoxication delirium appears to cause intense psychosis that can be managed with antipsychotic medications. Clinicians should be aware of this phenomenon until more precise detection methods are available.

Katz DA; Weg MWV; Holman J; Nugent A; Baker L; Johnson S et al. The Emergency Department Action In Smoking Cessation (EDASC) Trial: Impact on delivery of smoking cessation counseling. Academic Emergency Medicine 19(4): 409-420, 2012. (83 refs.)

Objectives: The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurseinitiated intervention on delivery of smoking cessation counseling based on the 5As framework (askadviseassessassistarrange) and 2) assess ED nurses and physicians perceptions of smoking cessation counseling. Methods: The authors conducted a prepost trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses and physicians self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable logistic regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates. Results: Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), and assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5) and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians (EPs). ED nurses self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in pros and cons attitudes toward smoking cessation in either ED nurses or physicians. Conclusions: Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.

Korcha RA; Cherpitel CJ; Moskalewicz J; Swiatkiewicz G; Bond J; Ye Y. Readiness to change, drinking, and negative consequences among Polish SBIRT patients. Addictive Behaviors 37(3): 287-292, 2012. (39 refs.)

The aim of this study is to examine the longitudinal relationship of readiness to change, drinking pattern, amount of alcohol consumed, and alcohol-related negative consequences among at-risk and dependent drinkers enrolled in a Screening, Brief Intervention and Referral to Treatment (SBIRT) trial in an emergency department in southern Poland. The study examined 299 patients randomized to either an assessment or intervention condition and followed at 3 and 12 months after initial presentation. Patients indicating a readiness or were unsure of changing drinking behavior were significantly more likely to decrease the maximum number of drinks per occasion and the usual number of drinks in a sitting in the 3-months following study entry when compared to those that rated changing drinking behavior as unimportant. Readiness to change was not predictive of outcomes between the baseline and 12-month follow-up. Drinking outcomes and negative consequences by readiness and research condition were non-significant. This is the first Polish study utilizing SBIRT to enable patients to identify their hazardous drinking and reduce alcohol consumption. While some drinking outcomes improved with motivation, these improvements were not maintained at 12-months following SBIRT. Attention to additional constructs of readiness to change and drinking patterns may augment the effectiveness of SBIRT.

Krul J; Girbes ARJ. Gamma-hydroxybutyrate: Experience of 9 years of gamma-hydroxybutyrate (GHB)-related incidents during rave parties in The Netherlands. Clinical Toxicology 49(4): 311- 315, 2011. (31 refs.)

Objective. The objective of this study was to determine the health disturbances and to assess the severity of the incidents as reported during a 9-year experience of gamma-hydroxybutyrate (GHB)-related First Aid Attendees attending First Aid Stations at rave parties. Design. This study was a prospective observational study of self-referred patients from the year 2000 to 2008. During rave parties, First Aid Stations were staffed with specifically trained medical and paramedical personnel. Patients were diagnosed and treated, and data were recorded using standardized methods. Results. During a 9-year period with 202 rave parties, involving approximately three million visitors, 22 604 First Aid Attendees visited the First Aid Stations, of which 771 reported GHB-related health problems. The mean age of the GHB-using First Aid Attendees was 25.7 +/- 6.1 years, most of them (66.4%) were male. Approximately one-third (32.7%) of them used one substance, while 48.1% combined GHB with ecstasy, alcohol, or cannabis. One of five (19.2%) combined GHB with other substances or more than one substance. One case was categorized as severe/life-threatening and 202 (26.2%) cases as moderate, requiring further medical care. In total, 43 (5.6%) First Aid Attendees needed hospital care. The most encountered health disturbance was altered consciousness. Combinations of altered consciousness, vomiting, and/or low body temperature were found in 186 cases (24.1%) and considered to be potentially dangerous. GHB-related First Aid Attendees required a longer stay at the First Aid Stations than the total group First Aid Attendees did (median 45 min vs 10 min). Conclusion. We found very little, severe short-term GHB-related health disturbances during rave parties in The Netherlands. Hospital referrals were rare. The most found symptom was altered consciousness, sometimes accompanied by vomiting and low body temperature. At events where the visitors use GHB, a well-trained and qualified medical team, including nurses and physicians, is recommendable. They must be able to recognize GHB intake and prevent secondary problems such as aspiration and hypothermia.

Latt N; Jurd S; Tennant C; Lewis J; Macken L; Joseph A et al. Alcohol and substance use by patients with psychosis presenting to an emergency department: Changing patterns. Australasian Psychiatry 19(4): 354-359, 2011. (14 refs.)

Objectives: The aim of this study was to determine the incidence of alcohol and other substance use in patients presenting to an emergency department with acute psychiatric illnesses and to clarify the role of urine drug screens. Method: This was an unblinded prospective (observational) cohort study incorporating retrospective review of patient medical records, history of alcohol and substance use, results of urine drug screens and blood alcohol concentrations. Results: Of 196 acute psychotic patients, 104 were diagnosed with schizophrenia and 92 with "other psychosis". Results of urine drug screens were consistent with self-reported use of substances and only identified an additional 5% of substance users. Cannabis was the commonest illicit substance used by both groups of patients, followed by psychostimulants, mainly amphetamines. Younger males were more likely to use psychostimulants and to present with violence. Conclusions: Patients with co-existing mental health problems and substance use present a major problem for our emergency departments. Cannabis was the most common substance used. Youth, male gender and psychostimulant use are associated with violent presentations. A comprehensive history of alcohol and substance use is important to implement appropriate dual diagnosis treatment. Urine drug screening is recommended for patients who do not admit to substance use.

Lee HKH; Ng HW; Tse ML; Lau FL. A retrospective survey on the clinical presentation of ketamine abusers in a Hong Kong emergency department. Hong Kong Journal of Emergency Medicine 18(4): 210-216, 2011. (12 refs.)

Objective: Ketamine is one of the commonest abusing agents in Hong Kong. Our study aims to identify their clinical pattern of presentations to emergency departments. Method: This is a retrospective survey study. The studied group was ketamine abusers being referred to us from a source out of emergency department (ED). Control group was randomly selected from patients attending our ED. The electronic records of the ketamine abusers and the controls in the past 3 years (1st April 2004-31st March 2007) were reviewed and analysed. Result: Total 91 subjects (48 in ketamine group, 43 in control group) were included. The mean age of ketamine abusers and control group are 21 and 22.2 year-old respectively. Most of them (97.9%) did not declare their background of ketamine abuse. The mean 3-year attendance rate for the ketamine group was 2.38 and for control group was 0.91, with a difference of 1.47 (95% CI 0.54-2.41, p=0.003). Most of their illnesses were diagnosed as epigastric pain (25%), followed by upper respiratory tract infection (18.8%), head injury (10.4%) and urinary tract infection (10.4%). Significantly higher number of ketamine abusers presented with epigastric pain compared with control group (odds ratio 143, p<0.001). Conclusion: Most teenage ketamine abusers do not declare their background of drug abuse when they present to emergency departments. They tend to have a higher frequency of attendances. Most of their presenting problems are related to gastrointestinal system.

Lejoyeux M; Gastal D; Bergeret A; Casalino E; Lequen V; Guillermet S. Alcohol use disorders among patients examined in emergency departments after a suicide attempt. European Addiction Research 18(1): 26-33, 2012. (23 refs.)

Aim of the Study: To assess the prevalence of alcohol use disorders (AUD) in a population of patients examined following attempted suicide and compare suicide attempts with and without AUD. Methods: 180 patients examined in an emergency department after a suicide attempt were compared with 180 controls paired for sex and age. All patients answered the CAGE and the Fagerstrom questionnaire. The DSM-IV-R criteria for alcohol, nicotine and cannabis abuse and dependence, as well as for borderline and antisocial personality, were checked. Results: The prevalence of AUD was 43% among suicide attempters. Suicide attempters with AUD were more often men (52 vs. 30%), living alone (64 vs. 31%) and older (35.9 vs. 32.3 years). They were more often dependent on nicotine (87 vs. 43%) and smoked more cannabis joints (1.4 vs. 0.5). They had taken alcohol before committing suicide more often (61 vs. 23%) and had more previous suicide attempts (2.5 vs. 0.9). Additionally, suicide attempters had higher scores of sensation seeking and presented more often with an antisocial or borderline personality. Conclusion: 43% of the patients examined after a suicide attempt presented with AUD. Emergency units may provide an opportunity to identify their dependence disorder and offer information and treatment.

Levine M; Ruha AM; Graeme K; Brooks DE; Canning J; Curry SC. Toxicology in the ICU Part 3: Natural toxins. Chest 140(5): 1357-1370, 2011. (141 refs.)

This is the third article of a three-part series that reviews the care of poisoned patients in the ICU. This article focuses on natural toxins, such as heavy metals and those produced by plants, mushrooms, arthropods, and snakes. The first article discussed the general approach to the patient, including laboratory testing; the second article focused on specific toxic agents, grouped into categories.

Li Y; Jensen GA. Effects of drinking on hospital stays and emergency room visits among older adults. Journal of Aging and Health 24(1): 67-91, 2012. (34 refs.)

Objective: To evaluate whether alcohol drinking influences emergency room (ER) visits or hospital admissions among adults aged 65 and older. Method: Data from two independent national surveys are used to estimate multivariate logit models that quantify the relationship between drinking and ER visits and hospital admissions. The authors distinguish between ER visits linked to a hospital admission for that individual and ER visits not linked to an admission. Results: The authors find no significant effects of alcohol consumption on either ER visits or hospital admissions among older adults. These findings occur in both data sets, and for both men and women. Distinguishing between different types of ER visits makes no difference. Discussion: Analysis of two large and nationally representative data sets suggests that among older adults drinking alcohol, or even heavily drinking alcohol, does not raise or lower the risk of a hospital admission or the risk of an ER visit.

Lin MT; Burgess JF; Carey K. The association between serious psychological distress and emergency department utilization among young adults in the USA. Social Psychiatry and Psychiatric Epidemiology 47(6): 939-947, 2012. (49 refs.)

Psychological problems could lead to several adverse health outcomes and were strongly correlated with cigarette smoking and alcohol consumption. In addition, patients treated in EDs were vulnerable to psychological problems. We therefore examined the population-level association between serious psychological distress (SPD) and emergency department (ED) use among young adults in the USA. We also studied the additive effects of SPD, cigarette smoking, and alcohol consumption on the ED presentation. The study sample contains 16,873 individuals, using data from the National Health Interview Survey, from 2004 to 2006. Bivariate analyses with chi-square tests and logistic regression analyses are performed. Young adults having SPD were 2.05 times more likely to go to an ED. People having SPD and being a current smoker were 2.52 times more likely to use services in an ED. However, people having SPD and being a heavy drinker did not have a significantly elevated risk of ED use. An association between SPD and ED use among US young adults is established in this study. Attempts to decrease excess ED use and the development of strategies to improve mental health among young adults are needed to improve patient health and reduce the health-care burden of high costs and deteriorating ED care quality.

Lipsky S; Caetano R. Intimate partner violence perpetration among men and emergency department use. Journal of Emergency Medicine 40(6): 696-703, 2011. (41 refs.)

Background: Intimate partner violence (IPV) perpetration and emergency department (ED) use share common risk factors, such as risk-taking behaviors, but little is known about the relationship between IPV perpetration and ED use or the effect of risk-taking on this relationship. Study Objectives: This study examined the relationship between IPV perpetration, risk-taking, and ED utilization among men in the general U.S. population. Methods: This cross-sectional study utilized data from the 2002 National Survey on Drug Use and Health, focusing on non-Hispanic white, non-Hispanic black, and Hispanic male respondents 18-49 years of age cohabiting with a spouse or partner. Logistic regression was used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI). Results: Approximately 38% of IPV perpetrators reported ED use in the previous year, compared to 24% of non-perpetrators. Several risk-taking factors (e.g., perception of risk-taking, transportation-related risk-taking, and aggression-related arrest), alcohol and illicit drug use and abuse or dependence, and serious mental illness were positively associated with IPV perpetration. Men reporting IPV were 1.5 times (AOR 1.47, 95% CI 1.01-2.13) more likely than non-perpetrators to utilize the ED, after taking all factors into account. Drug abuse or dependence, transportation-related risk behaviors, and serious mental illness also were independently associated with ED use. Conclusions: The results indicate that men who perpetrate IPV are more likely than non-perpetrators to use ED services. These findings suggest that screening for IPV, as well as risk-taking and mental illness among men accessing ED services may increase opportunities for intervention and referral.

Lloyd BK; McElwee PR. Trends over time in characteristics of pharmaceutical drug-related ambulance attendances in Melbourne. Drug and Alcohol Review 30(3): 271- 280, 2011. (30 refs.)

Introduction and Aims. There is growing concern regarding pharmaceutical drug-related harms. Evidence suggests increasing non-medical use of pharmaceutical drugs, along with associated morbidity and mortality. This paper explores trends of pharmaceutical-related ambulance attendances over the past decade in order to identify populations experiencing acute harm, and levels of harms in the community. Design: and Methods. A retrospective analysis of pharmaceutical drug-related ambulance attendances in metropolitan Melbourne, Australia, is presented, with rates of attendances over the period 2000 to 2009 and change over time examined. Characteristics of attendances are explored to understand the nature of presentation and demographic characteristics. Results. Benzodiazepines represented the drug group with the highest rates of attendances over the 10 year period. Rates of attendances increased significantly for opioid analgesics, while significant decreases were noted for benzodiazepines, antidepressant and anticonvulsants. While women represented the majority of patients for each drug category presented over the period examined, there was an increase in the proportion of men attended in relation to opioid analgesics. Alcohol involvement in presentations has increased significantly for all drug groups. Discussion and Conclusions. Increasing pharmaceutical-related ambulance attendances for opioid analgesics reflect increasing use, with the increase in other analgesic-related attendances also concerning. The overrepresentation of female patients reflects a population experiencing drug-related harm not reflected in illicit drug research. The rise of alcohol involvement represents heightened risk of adverse events including death, and suggests an area for public education to prevent alcohol and drug-related harms.

Lunsky Y; Elserafi J. Life events and emergency department visits in response to crisis in individuals with intellectual disabilities. Journal of Intellectual Disability Research 55(Part 7, special issue): 714-718, 2011. (15 refs.)

Background: Stressful life events have been linked to psychopathology in the general population, but few studies have considered the relationship between life events and psychopathology for people with intellectual disabilities (ID), and the link between particular life events and hospital use. Methods. Informants provided data on 746 adults with ID who had experienced at least one 'crisis'. Informants completed a checklist of recent life events from the Psychiatric Assessment for Adults with Developmental Disabilities Checklist (PAS ADD checklist) and also indicated whether the crisis resulted in a visit to the hospital emergency department. Results. Individuals experiencing life events in the past year were more likely to visit the emergency department in response to crisis than those who did not experience any life events. Individuals experiencing a move of house or residence, serious problem with family, friend or caregiver, problems with police or other authority, unemployed for more than 1 month, recent trauma/abuse, or a drug or alcohol problem were more likely to visit the emergency department. Conclusions. Six specific life events were found to be associated with use of emergency departments in response to crisis. We suggest intervention efforts be targeted towards people who experience life events, particularly these events, as they may be a risk factor for hospital visits.

Lust EB; Barthold C; Malesker MA; Wichman TO. Human health hazards of veterinary medications: Information for emergency departments. Journal of Emergency Medicine 40(2): 198-207, 2011. (59 refs.)

Background: There are over 5000 approved prescription and over-the-counter medications, as well as vaccines, with labeled indications for veterinary patients. Of these, there are several products that have significant human health hazards upon accidental or intentional exposure or ingestion in humans: carfentanil, clenbuterol (Ventipulmin), ketamine, tilmicosin (Micotil), testosterone/estradiol (Component E-H and Synovex H), dinoprost (Lutalyse/Prostamate), and cloprostenol (Estromate/EstroPlan). The hazards range from mild to life-threatening in terms of severity, and include bronchospasm, central nervous system stimulation, induction of miscarriage, and sudden death. Objective: To report medication descriptions, human toxicity information, and medical management for the emergent care of patients who may have had exposure to veterinary medications when they present to an emergency department (ED). Discussion: The intended use of this article is to inform and support ED personnel, drug information centers, and poison control centers on veterinary medication hazards. Conclusion: There is a need for increased awareness of the potential hazards of veterinary medications within human medicine circles. Timely reporting of veterinary medication hazards and their medical management may help to prepare the human medical community to deal with such exposures or abuses when time is of the essence.

Marshall BDL; Grafstein E; Buxton JA; Qi J; Wood E; Shoveller JA et al. Frequent methamphetamine injection predicts emergency department utilization among street-involved youth. Public Health 126(1): 47-53, 2012. (33 refs.)

Objectives: Methamphetamine (MA) use has been associated with health problems that commonly present in the emergency department (ED). This study sought to determine whether frequent MA injection was a risk factor for ED utilization among street-involved youth. Study design: Prospective cohort study. Methods: Data were derived from a street-involved youth cohort known as the 'At Risk Youth Study'. Behavioural data including MA use were linked to ED records at a major inner-city hospital. Kaplan-Meier and Cox proportional hazards methods were used to determine the risk factors for ED utilization. Results: Between September 2005 and January 2007, 427 eligible participants were enrolled, among whom the median age was 21 (interquartile range 19-23) years and 154 (36.1%) were female. Within 1 year, 163 (38.2%) visited the ED, resulting in an incidence density of 53.7 per 100 person-years. ED utilization was significantly higher among frequent (i.e. >= daily) MA injectors (log-rank P = 0.004). In multivariate analysis, frequent MA injection was associated with an increased hazard of ED utilization (adjusted hazard ratio = 1.84, 95% confidence interval 1.04-3.25; P = 0.036). Conclusions: Street-involved youth who frequently inject MA appear to be at increased risk of ED utilization. The integration of MA-specific addiction treatment services within emergency care settings for high-risk youth is recommended.

Massey SH; Norris L; Lausin M; Nwaneri C; Lieberman DZ. Identifying harmful drinking using a single screening question in a psychiatric consultation-liaison population. Psychosomatics 52(4): 362-366, 2011. (22 refs.)

Background: Harmful drinking is common in medical inpatients, yet commonly missed due in part to time pressures. A screening question about past year heavy drinking recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has been validated in primary care and emergency room settings. We tested the psychometric properties of a modified single screening question (SSQ) in hospitalized patients referred to a consultation-liaison service. Methods: A psychiatry attending (n = 40), a psychiatry resident (n = 30) and a medical student (n = 30) administered the SSQ, followed by a self-report 10-item Alcohol Use Disorders Identification Test (AUDIT) to a sample of 100 consultation-liaison patients who were able to give informed consent for participation. Results: Using the AUDIT as a reference, the sensitivity and specificity of the SSQ to detect harmful drinking in this sample were .96 and .82, respectively. Gender differences in specificity were not found. The single question also had a strong correlation with dependence (r(b) = .457, p < .001), and harmful use (r(b) = .620, p < .001) subscales of the AUDIT. Conclusion: The SSQ about past year heavy drinking can rapidly identify harmful drinking in alert nonpsychotic consultation-liaison patients. [Note: "The" question, after asking if someone sometimes drinks beer wine, or other alcoholic beverages is "Have you had five or more drinks (four or more for women) in a single day in the past year?". A response of yes is considered positive and indicating the need for a more comprehensive assessment.]

McCabe CT; Woodruff SI; Zuniga ML. Sociodemographic and substance use correlates of tobacco use in a large, multi-ethnic sample of emergency department patients. Addictive Behaviors 36(9): 899-905, 2011. (45 refs.)

Strong evidence suggests marked disparities among ethnic minorities in relation to tobacco use. To date, a majority of the data available discusses tobacco use in the general population. Using a sample of Latino, non-Latino Black (NLB), and non-Latino White (NLW) patients presenting to the emergency departments, the present study examined sociodemographic and substance use correlates of past 3-month tobacco use. Over 48,000 patients were interviewed as part of a screening and brief intervention program in southern California. Overall, although NLB adults reported the greatest prevalence of tobacco use compared to NLWs and Latinos (43% vs. 34% and 22% respectively), associations between tobacco use, demographics and substance use were similar across groups. Males, younger individuals, those with lower income, and being at higher risk for alcohol and drug use were more likely to report recent tobacco use. Future tobacco interventions in emergency settings should highlight these specific risk factors for Latinos, NLBs, and NLWs.

McDonell MG; Hsiao RC; Russo J; Pasic J; Ries RK. Clinical prevalence and correlates of substance use in adolescent psychiatric emergency patients. Pediatric Emergency Care 27(5): 384- 389, 2011. (38 refs.)

Objectives: This study used clinical and administrative data to describe the clinical prevalence and correlates of substance use disorders (SUDs) in 622 adolescents aged 12 to 17 years who were evaluated with 1 or more psychiatric diagnoses after presenting to an urban psychiatric emergency service. Methods: Clinical and administrative data including demographics, diagnosis, psychiatric severity, suicidality, treatment history, treatment disposition, social support, and overall functioning were retrospectively obtained from patient records. These data were used to describe the prevalence and correlates of SUDs in this sample of adolescents with psychiatric disorders. Results: Twenty-eight percent of youth had an SUD. Marijuana and alcohol use disorders were the most common. The diagnosis of SUD was not associated with specific psychiatric diagnostic categories (mood, anxiety, and psychotic), psychiatric symptom severity, or suicidality, in the overall sample. There was limited evidence for a mediating/moderating effect of sex on the correlation between psychiatric measures and SUD diagnosis. Older age, SUD treatment history, and role dysfunction (ie, poor school functioning) were independently associated with any SUD diagnosis or a drug use disorder when accounting for sex. Older age and history of SUD treatment were independently correlated with alcohol use disorders. Twenty-three percent of youth with SUDs were referred for SUD treatment. Conclusions: Substance use disorders were prevalent in this population, and the rate of SUD treatment disposition was lower than anticipated. Substance use disorders were associated with lower functioning but not independently correlated with psychiatric diagnostic categories or symptom severity. This study supports the need for improved screening, intervention, and referral options for SUDs in this setting.

McMicken D; Liss JL. Alcohol-related seizures. Emergency Medicine Clinics of North America 29(1): 117-+, 2011. (42 refs.)

The term alcohol-related seizures (ARS) is used to refer to all seizures in the aggregate associated with alcohol use, including the subset of alcohol withdrawal seizures (AWS). From 20% to 40% of patients with seizure who present to an emergency department have seizures related to alcohol abuse. However, it is critical to avoid prematurely labeling a seizure as being caused by alcohol withdrawal before performing a careful diagnostic evaluation. Benzodiazepines alone are sufficient to prevent AWS. The alcoholic patient with a documented history of ARS, who experiences a single seizure or a short burst of seizures should be treated with lorazepam, 2 mg intravenously.

Merrick ESL; Hodgkin D; Garnick DW; Horgan CM; Panas L; Ryan M et al. Older adults' inpatient and emergency department utilization for ambulatory-care-sensitive conditions: Relationship with alcohol consumption. Journal of Aging and Health 23(1): 86-111, 2011. (60 refs.)

Objective: This study examined the relationship between drinking that exceeds guideline-recommended limits and acute-care utilization for ambulatory-care-sensitive conditions (ACSCs) by older Medicare beneficiaries. Method: This secondary data analysis used the 2001-2006 Medicare Current Beneficiary Survey (unweighted n = 5,570 community dwelling, past-year drinkers, 65 years and older). Self-reported alcohol consumption (categorized as within guidelines, exceeding monthly but not daily limits, or heavy episodic) and covariates were used to predict ACSC hospitalization, emergency department visit not resulting in admission, and emergency department visit that did result in admission. Results: Heavy episodic drinking was significantly associated with higher likelihood of an ACSC emergency department visit not resulting in admission (adjusted odds ratio = 1.91, 95% CI: 1.11-3.30; p < .05). Drinking pattern was not significant for other ACSC measures. Discussion: Results partially support the hypothesis that excessive drinking may be related to ACSC acute-care utilization among older adults, suggesting increased risk of lower quality outpatient care.

Mirmoghtadaee P; Eizadi-Mood N; Sabzghabaee AM; Yaraghi A; Hosseinzadeh F; Dorvashi G. Risk factors for endotracheal intubation and mechanical ventilation in patients with opioids intoxication. Pakistan Journal of Medical Sciences 28(2): 279-282, 2012. (19 refs.)

Objectives: Patients poisoned with opioids sometimes need endotracheal intubation with or without the use of mechanical ventilation. This study was done to determine the prognostic risk factors for of the need for endotracheal intubation and mechanical ventilation. Methodology: In this cross-sectional study which was performed in Isfahan (Iran), one hundred (n = 100) opioid poisoned patients whom their overdoses were diagnosed by their full and reliable history, physical examination and positive response to naloxone; vital signs at the hospital admission, blood biochemistry, ABG details and also the type and estimated dosage of opioid, route of consumption, and their need to mechanical ventilation were evaluated. Results: Patients were mostly aged between 20-40 years old. Seventy nine patients were male and 26 cases (21 men) required endotracheal intubation and 15 cases (14 men) needed both intubation and mechanical ventilation. The most consumed opiates among the poisoned patients were opium (35%), heroin (16%), Tramadol (15%), Methadone (9%), crack (6%), Diphenoxylate (4%) and others (15%). There was a significant difference between the mean heart rates and respiratory rate of the patients who were connected to the ventilator and others (99.8 +/- 21.8 and 87.3 +/- 16.3; p = 0.01). The lower level of consciousness [OR: 2.2 95% Confidence Interval (CI): 1.2-4.2], and lower admission level of hemoglobin (OR: 3.6; CI: 1.2-10.8) were among the factors for predicting the need for intubation and ventilation. Conclusion: Determining the risk factors with prognostic value for the need to intubation or ventilation seems to be necessary for improving the standard of therapy in opioids poisoned patients.

Moreira M; Buchanan J; Heard K. Validation of a 6-hour observation period for cocaine body stuffers. American Journal of Emergency Medicine 29(3): 299-303, 2011. (13 refs.)

Often, patients are brought in to the emergency department after ingesting large amounts of cocaine in an attempt to conceal it. This act is known as body staffing. The observation period required to recognize potential toxic adverse effects in these patients is not well described in the literature. We sought to validate a treatment algorithm for asymptomatic cocaine body stuffers using a 6-hour observation period by observing the clinical course of cocaine body stuffers over a 24-hour period. A retrospective chart review was performed on all patients evaluated for witnessed or suspected stuffing over 2 years using a standardized protocol. One hundred six patients met final inclusion criteria as adult cocaine stuffers. No patients developed life-threatening symptoms, and no patients died during observation. In our medical setting, starers could be discharged after a 6-hour observation period if there was either complete resolution or absence of clinical symptoms.

Mundt MP; Zakletskaia LI. Prevention for college students who suffer alcohol-induced blackouts could deter high-cost emergency department visits. Health Affairs 31(4): 863-870, 2012. (34 refs.)

Fifty percent of college students who drink report alcohol-induced blackouts, and alcohol abusers in general put a heavy burden on the medical care system. Using data drawn from a randomized, controlled alcohol intervention trial at five university sites, our study quantified the costs of visits to emergency departments by college students who experienced blackouts from drinking alcohol. Of 954 students in the study, 52 percent of males and 50 percent of females at the outset of the study had experienced an alcohol-induced blackout in the past year. Of 404 emergency department visits among the study participants over a two-year observation period, about one in eight were associated with blackout drinking. Injuries ranged from broken bones to head and brain injuries requiring computed tomography. We calculate that on a large university campus having more than 40,000 students, blackout-associated emergency department visit costs would range from $469,000 to $546,000 per year. We conclude that blackouts are a strong predictor of emergency department visits for college drinkers and that prevention efforts aimed at students with a history of blackouts might reduce injuries and emergency department costs.

Naun CA; Olsen CS; Dean JM; Olson LM; Cook LJ; Keenan HT. Can poison control data be used for pharmaceutical poisoning surveillance? Journal of the American Medical Informatics Association 18(3): 225- 231, 2011. (30 refs.)

Objective To determine the association between the frequencies of pharmaceutical exposures reported to a poison control center (PCC) and those seen in the emergency department (ED). Design: A statewide population-based retrospective comparison of frequencies of ED pharmaceutical poisonings with frequencies of pharmaceutical exposures reported to a regional PCC. ED poisonings, identified by International Classification of Diseases, Version 9 (ICD-9) codes, were grouped into substance categories. Using a reproducible algorithm facilitated by probabilistic linkage, codes from the PCC classification system were mapped into the same categories. A readily identifiable subset of PCC calls was selected for comparison. Measurements Correlations between frequencies of quarterly exposures by substance categories were calculated using Pearson correlation coefficients and partial correlation coefficients with adjustment for seasonality. Results: PCC reported exposures correlated with ED poisonings in nine of 10 categories. Partial correlation coefficients (r(p)) indicated strong associations (r(p)>0.8) for three substance categories that underwent large changes in their incidences (opiates, benzodiazepines, and muscle relaxants). Six substance categories were moderately correlated (r(p)>0.6). One category, salicylates, showed no association. Limitations Imperfect overlap between ICD-9 and PCC codes may have led to miscategorization. Substances without changes in exposure frequency have inadequate variability to detect association using this method. Conclusion PCC data are able to effectively identify trends in poisonings seen in EDs and may be useful as part of a pharmaceutical poisoning surveillance system. The authors developed an algorithm-driven technique for mapping American Association of Poison Control Centers codes to ICD-9 codes and identified a useful subset of poison control exposures for analysis.

Neighbor ML; Dance TR; Hawk M; Kohn MA. Heightened pain perception in illicit substance-using patients in the ED: implications for management. American Journal of Emergency Medicine 29(1): 50-56, 2011. (34 refs.)

Background: Substance users are commonly perceived to overstate their pain. Few data exist comparing pain intensity, perception, and related psychiatric comorbidities in the emergency department (ED) population. Objective: To compare pain severity, duration, interference with function, and psychiatric and mood disturbance in substance-using (SU) and non substance-using (NSU) patients in the ED. Methods: This is a cross-sectional study. The setting is in an urban ED. Participants are SU and NSU patients in moderate to severe pain (numerical rating scale, 5-10). Outcome measures are as follows: pain intensity and duration, other painful conditions, pain-related functional interference (0-10), psychiatric disorders, and mood distress (profile of mood scale, 0-44). Results: Of the 148 patients who enrolled, 28 (19%) reported recent illicit substance use (SU) and 120(81%) did not (NSU). The SU patients' mean pain intensity was 8.96 (confidence interval [CI], 7.47-8.14) vs 7.81 (CI, 8.48-9.45) for NSU (P = .003). The SU patients reported higher levels of pain interference. Fifty-four percent of SU patients vs 31% of NSU patients reported a psychiatric illness (P = .02). Mean Profile of Mood State score was higher in SU (32.3; CI, 27.4-37.1) than in NSU (22.5; CI, 20.2-24.8; P<.001). Chronic pain was reported by 29% of SU patients vs 16% of NSU patients, and 75% of SU patients vs 58% of NSU patients reported another concurrent painful condition (P = .10). Conclusions: The SU patients report more severe pain and functional interference, more psychiatric illness and mood distress, and more chronically painful conditions. Given the complex interplay between pain, substance use, and mood disorders, increased attention should be paid to identifying patients with these associated conditions and to facilitating appropriate referrals. Effective treatment of this challenging patient population requires treating the entirety of their medical, psychiatric, and addictive diseases.

Newton AS; Gokiert R; Mabood N; Ata N; Dong K; Ali S et al. Instruments to detect alcohol and other drug misuse in the emergency department: A systematic review. (review). Pediatrics 128(1): E180-E192, 2011. (50 refs.)

CONTEXT: Alcohol and other drug (AOD) misuse by youth is a significant public health concern. Unanticipated treatment for AOD-related morbidities is often sought in hospital emergency departments (EDs). Screening instruments that rapidly identify patients who require further diagnostic evaluation and/or brief intervention are critically important. OBJECTIVE: To summarize evidence on screening instruments that can assist emergency care clinicians in identifying AOD misuse in pediatric patients. METHODS: Fourteen electronic databases (including Medline, Embase, and PsycINFO) and reference screening were used. Psychometric and prospective diagnostic studies were selected if the instrument focused on detecting AOD misuse in patients aged 21 years or younger in the ED. Two reviewers independently assessed quality and extracted data. Validity and reliability data were collected for psychometric studies. Instrument performance was assessed by using sensitivity, specificity, and positive (LR+) and negative (LR-) likelihood ratios. Meta-analysis was not possible because of clinical and measurement heterogeneity. RESULTS: Of the 1545 references initially identified, 6 studies met inclusion criteria; these studies evaluated 11 instruments for universal or targeted screening of alcohol misuse. Instruments based on diagnostic criteria for AOD disorders were effective in detecting alcohol abuse and dependence (sensitivity: 0.88; specificity: 0.90; LR+ : 8.80) and cannabis use disorder (sensitivity: 0.96; specificity: 0.86; LR+: 6.83). CONCLUSIONS: On the basis of the current evidence, we recommend that emergency care clinicians use a 2-question instrument for detecting youth alcohol misuse and a 1-question instrument for detecting cannabis misuse. Additional research is required to definitively answer whether these tools should be used as targeted or universal screening approaches in the ED.

Nielsen K; Nielsen SL; Siersma V; Rasmussen LS. Treatment of opioid overdose in a physician-based prehospital EMS: Frequency and long-term prognosis. Resuscitation 82(11): 1410-1413, 2011. (14 refs.)

Background: Prehospital treatment of opioid overdose accounts for a significant proportion of the workload of the emergency system in most major cities. Treatment consists of basic life support and administering naloxone. In our physician-manned mobile emergency care unit (MECU), most patients are released and not admitted to hospital. In this study, we aimed to assess the pattern in the number of episodes with opioid overdose treated by MECU in Copenhagen during a 10-year period and to investigate risk factors for mortality of these patients beyond the initial contact. Methods: Data were collected prospectively in the MECU database covering all cases of opioid overdose in a 10-year period between 1994 and 2003. The pattern in the number of opioid overdose was analysed in Poisson regression models, and mortality was analysed in Kaplan-Meier plots and in Cox regression models. Results: A total of 4762 episodes of opioid overdose were recorded. Patients were identified in 3245 of these episodes. The annual number of episodes decreased significantly over the data-collection period: from 639 overdoses out of 4520 (14.1%) patients treated in 1994 to 311 out of 7263 patients treated (4.3%) in 2003. A total of 352 patients had cardiac arrest at the scene. The MECU released 2246 patients (69.3%) after treatment, while 675 (20.8%) were admitted to hospital and 322 (9.9%) died. Long-term prognosis was poor with 14% mortality at 1 year. Long-term mortality was significantly related to increasing age, time of the year and if the patient had previous episodes of opioid overdose. Conclusions: There has been a significant decrease in the number of opioid overdoses during this 10-year-period. Long-term mortality is high in these patients and highest in those with advanced age and numerous episodes of opioid overdose.

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Metro Briefs: Drug-Related Emergency Department Visits in Metropolitan Areas. (April 28, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011

This is a series of 11 DAWN publications that focus upon a metropolitan area. Prepared by the DAWN network, these eleven individual reports describe drug-related presentations to emergency departments in the following cities: Boston, Chicago, Denver, Detroit, Miami, Minneapolis, New York City, Phoenix, San Diego, San Francisco, and Seattle. Each of the Metro Reports provides information on the number of cases reported, demographic characteristics, the drugs involved, both prescription and illicit drugs, and provides a comparison of city level data to national data, presentations by underage drinkers, visits involving drug-related suicide attempts. A glossary for the drugs mentioned is included which describes the drug's action, medical use, and common problems related to use.

O'Mara RM; Hill RM; Cunningham RM; King CA. Adolescent and parent attitudes toward screening for suicide risk and mental health problems in the pediatric emergency department. Pediatric Emergency Care 28(7): 626-632, 2012. (22 refs.)

Objective: The objective of this study was to investigate adolescent and parent attitudes toward screening adolescents for suicide risk and other mental health problems in the emergency department (ED). Methods: Two hundred ninety-four adolescents and 300 parents completed questionnaires about the importance of screening for suicide risk and other mental health problems in the ED, what would be helpful if the screen was positive, their concerns about screening in the ED, whether they believe screening should be a routine part of an ED visit, and whether they would complete a screening during the current visit if offered the opportunity. Results: Overall, parents and adolescents reported positive attitudes toward screening for suicide risk and other mental health problems in the ED, with the majority responding that it should be a routine part of ED care. Suicide risk and drug and alcohol misuse were rated as more important to screen for than any of the other mental health problems by both parents and adolescents. Adolescent females and mothers were more supportive of screening for suicide risk and mental health problems in the ED than male adolescents and fathers. Descriptive data regarding screening concerns and follow-up preferences are reported. Conclusions: Study results suggest overall positive support for screening for suicide risk and other mental health problems in the ED, with some important preferences, concerns, and parent versus adolescent and male versus female differences.

Ozhathil DK; Abar B; Baumann BM; Camargo CA; Ziedonis D; Boudreaux ED. The effect of removing cost as a barrier to treatment initiation with outpatient tobacco dependence clinics among emergency department patients. Academic Emergency Medicine 18(6): 662-664, 2011. (10 refs.)

Objectives: The campaign against tobacco addiction and smoking continues to play an important role in public health. However, referrals to outpatient tobacco cessation programs by emergency physicians are rarely pursued by patients following discharge. This study explored cost as a barrier to follow-up. Methods: The study was performed at a large urban hospital emergency department (ED) in Camden, New Jersey. Enrollment included adults who reported tobacco use in the past 30 days. Study participants were informed about a "Stop Smoking Clinic" affiliated with the hospital and, depending on enrollment date, cost of treatment was advertised as $150 (standard fee), $20 (reduced fee), or $0 (no fee). Monitoring of patient inquiries and visits to the clinic was performed for 6 months following enrollment of the last study subject. Results: The analyzed sample consisted of 577 tobacco users. There were no statistically significant demographic differences between treatment groups (p > 0.05). Two-hundred forty-seven (43%) participants reported "very much" interest in smoking cessation. However, there was no significant difference in initiating treatment with the Stop Smoking Clinic across experimental condition. Only a single subject, enrolled in the no-fee phase, initiated treatment with the clinic. Conclusions: Cost is unlikely to be the only barrier to pursing outpatient tobacco treatment after an ED visit. Further research is needed to determine the critical components of counseling and referral that maximize postdischarge treatment initiation.

Pedapati EV; Bateman ST. Toddlers requiring pediatric intensive care unit admission following at-home exposure to buprenorphine/naloxone. Pediatric Critical Care Medicine 12(2): E102-E107, 2011. (38 refs.)

Background: Sublingual buprenorphine is an alternative to methadone for office-based treatment of opioid dependence. Recent reports have examined a growing number of unintentional buprenorphine exposures in children resulting in significant toxicity, even after a single lick or taste of a sublingual tablet. Here, we report a series of unintentional buprenorphine exposures in toddlers over a 2.5-yr period that led to admission to the pediatric intensive care unit. Objectives: The goals of this study were to determine: 1) the prevalence of symptomatic buprenorphine exposure in children < 3 yrs of age; 2) the severity of toxicity associated with such exposures; and 3) effective clinical interventions. Methods and Main Results: A retrospective case review was performed on records from the pediatric intensive care unit at an academic medical center located in the northeastern United States. Unintentional buprenorphine/naloxone exposure (n = 9) accounted for the largest single fraction of toxic ingestions among patients younger than 3 yrs within the study period (9/33, 27%). All exposures occurred at the child's place of residence n = 9, 100%). Clinical signs of opioid toxicity were evident in all nine cases, with the most common symptom being drowsiness or lethargy (n = 9, 100%), followed by miosis (n = 6, 67%) and respiratory depression (n = 5, 56%). Six patients were effectively treated with naloxone (n = 6, 67%). Conclusions: The increased use and similarity to candy of the current formulation of buprenorphine pose a special risk to children, especially toddlers. Buprenorphine exposure in children < 3 yrs old can cause significant opioid toxidrome. Naloxone is an effective agent for reversal of symptoms; however, given buprenorphine's high affinity and long action, higher doses or continuous infusion may be required. Adults on buprenorphine should be educated on the risks posed to young children in their household and the appropriate storage of medication.

Perron BE; Bohnert ASB; Monsell SE; Vaughn MG; Epperson M; Howard MO. Patterns and correlates of drug-related ED visits: Results from a national survey. American Journal of Emergency Medicine 29(7): 704-710, 2011. (28 refs.)

Purpose: Drug treatment can be effective in community-based settings, but drug users tend to underuse these treatment options and instead seek services in emergency departments (EDs) and other acute care settings. The goals of this study were to describe prevalence and correlates of drug-related ED visits. Basic Procedures: This study used data from the National Epidemiologic Survey on Alcohol and Related Conditions, which is a nationally representative survey of 43,093 US residents. Main Findings: The overall prevalence of drug-related ED visits among lifetime drug users was 1.8%; for those with a lifetime drug use disorder, 3.7%. Persons with heroin dependence and inhalant dependence had the highest rates of ED visits, and marijuana dependence was associated with the lowest rates. Multivariate analyses revealed that being socially connected (ie, marital status) was a protective factor against ED visits, whereas psychopathology (ie, personality or mood disorders) was a risk factor. Conclusions: Significant variability exists for risk of ED use for different types of drugs. These findings can help inform where links between EDs with local treatment programs can be formed to provide preventive care and injury-prevention interventions to reduce the risk of subsequent ED visits.

Peterson TA; Desmond JS; Cunningham R. Use of an administrative data set to determine optimal scheduling of an alcohol intervention worker. Journal of Emergency Medicine 42(6): 712-718, 2012. (16 refs.)

Background: Brief alcohol interventions are efficacious in reducing alcohol-related consequences among emergency department (ED) patients. Use of non-clinical staff may increase alcohol screening and intervention; however, optimal scheduling of an alcohol intervention worker (AIW) is unknown. Objectives: Determine optimal scheduling of an AIW based on peak discharge time of alcohol-related ED visits. Methods: Discharge times for consecutive patients with an alcohol-related diagnosis were abstracted from an urban ED's administrative data set from September 2005 through August 2007. Queuing theory was used to identify optimal scheduling. Data for weekends and weekdays were analyzed separately. Stationary independent period-by-period analysis was performed for hourly periods. An M/M/s queuing model, for Markovian inter-arrival time/Markovian service time/and potentially more than one server, was developed for each hour assuming: 1) a single unlimited queue; 2) 75% of patients waited no longer than 30 min for intervention; 3) AIW spent an average 20 min/patient. Estimated average utilization/hour was calculated; if utilization/hour exceeded 25%, AIW staff was considered necessary. Results: There were 2282 patient visits (mean age 38 years, range 11-84 years). Weekdays accounted for 45% of visits; weekends 55%. On weekdays, one AIW from 6:00 a.m.-9:00 a.m. (max utilization 42%/hour) would accommodate 28% of weekday alcohol-related patients. On weekends, 5:00 a.m.-11:00 a.m. (max utilization 50%), one AIW would cover 54% of all weekend alcohol-related visits. During other hours the utilization rate falls below 25%/hour. Conclusions: Evaluating 2 years of discharge data revealed that 30 h of dedicated AIW time-18 weekend hours (5:00 a.m.-11:00 a.m.), 12 weekday hours (6:00 a.m.-9:00 a.m.) would allow maximal patient alcohol screening and intervention with minimal additional burden to clinical staff.

Rachamim E; Hodes D; Gilbert R; Jenkins S. Pattern of hospital referrals of children at risk of maltreatment. Emergency Medicine Journal 28(11): 952-954, 2011. (14 refs.)

Background Increasingly emergency departments (ED) and other acute services in the hospital provide first access care, especially out of hours and for poorer families. Studies of detection of child maltreatment in the hospital have focused on children presenting with injury, although maltreatment may be suspected when parents present to the hospital with problems related to violent behaviour, drug abuse or mental health problems. Methods A consecutive case series is described of patients referred for suspected child maltreatment from one inner-city general hospital after training was given to clinical staff and 2 years after the creation of a new post comprising a full-time, experienced child protection advisor (CPA) on-site to support clinicians with concerns about child maltreatment. Results There were 44 referrals to the CPA over 2 months in 2005, of whom just under half were initiated by clinicians caring for a parent. 15 referrals came from the ED (five followed a parent presenting to the ED), 14 from maternity obstetric services, and 15 from the neonatal or paediatric wards. Most families (38; 86%) were referred by nurses. One-quarter of referrals were already known to children's social care. Conclusions Clinicians need to be aware that half the vulnerable children in hospital are identified through one or other parent. It is hypothesised that the availability of an experienced child protection advisor on-site, combined with child protection training, makes it possible for clinicians caring for adults with problems related to violence, drug abuse or acute mental illness, to take action to address the potential vulnerability of their children.

Ranney ML; Whiteside L; Walton MA; Chermack ST; Zimmerman MA; Cunningham RM. Sex differences in characteristics of adolescents presenting to the emergency department with acute assault-related injury. Academic Emergency Medicine 18(10): 1027-1035, 2011. (74 refs.)

Objectives: Adolescents with a history of peer assault are known to report high rates of other risky behaviors. The characteristics of adolescents seeking care in the ED for acute assault-related injury are less well established. This knowledge deficit is particularly noticeable for adolescent female victims of peer assault. This study's objectives were: 1) to characterize the demographics and risk behaviors of youths presenting to the emergency department (ED) with acute assault-related injury and 2) to compare assaulted youths' demographic characteristics, past experiences with violence, and other risk behaviors by sex. Methods: A systematic sample of adolescents (ages 14 to 18 years) presenting to an urban ED with acute assault-related injury (excluding dating violence, sexual assault, and child abuse) was recruited. Consenting participants self-administered a computerized survey about demographics, history of peer and dating aggression, and theoretical correlates of violence (e. g., alcohol and other drug use, depressive symptoms, weapon carriage). Multivariate logistic regression was performed to identify factors that were differentially associated with presentation to the ED for acute assault-related injury for females versus males. Results: Of 3,338 adolescents completing a screening survey during the 36-month study period, 197 had presented to the ED with acute assault-related injuries; seven of these were excluded from this study due to being victims of dating violence. Most (n = 179, 94.2%) of these 190 acutely assaulted participants were discharged home. The majority reported a history of past-year peer aggression (n = 160, 84.2%) and past-year violent injury (n = 106, 55.8%). Similar rates of past-year peer aggression, past-year violent injury, alcohol use, and weapon carriage were observed for adolescent males and females presenting with acute assault-related injury. Males and females also reported similar age, race, socioeconomic status, and education levels. Compared to males, females were less likely to report living with a parent (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.08 to 0.84) and were more likely to report depressive symptoms (OR = 2.59, 95% CI = 1.23 to 5.48) and past-year dating aggression (OR = 2.23, 95% CI = 1.04 to 4.82). Conclusions: Male and female adolescents with acute assault-related injuries were very similar. Both reported extremely high rates of past year peer violence, assault-related injury, and substance use. The greater prevalence of some risk factors among adolescent females, such as depressive symptoms, dating aggression, and independent living status, should be further investigated.

Rhodes KV; Kothari CL; Dichter M; Cerulli C; Wiley J; Marcus S. Intimate partner violence identification and response: Time for a change in strategy. Journal of General Internal Medicine 26(8): 894-899, 2011. (35 refs.)

BACKGROUND: While victims of intimate partner violence (IPV) present to health care settings for a variety of complaints; rates and predictors of case identification and intervention are unknown. OBJECTIVE: Examine emergency department (ED) case finding and response within a known population of abused women. DESIGN: Retrospective longitudinal cohort study. SUBJECTS: Police-involved female victims of IPV in a semi-rural Midwestern county. MAIN MEASURES: We linked police, prosecutor, and medical record data to examine characteristics of ED identification and response from 1999-2002; bivariate analyses and logistic regression analyses accounted for the nesting of subjects' with multiple visits. RESULTS: IPV victims (N = 993) generated 3,426 IPV-related police incidents (mean 3.61, median 3, range 1-17) over the 4-year study period; 785 (79%) generated 4,306 ED visits (mean 7.17, median 5, range 1-87), which occurred after the date of a documented IPV assault. Only 384 (9%) ED visits occurred within a week of a police-reported IPV incident. IPV identification in the ED was associated with higher violence severity, being childless and underinsured, more police incidents (mean: 4.2 vs 3.3), and more ED visits (mean: 10.6 vs 5.5) over the 4 years. The majority of ED visits occurring after a documented IPV incident were for medical complaints (3,378, 78.4%), and 72% of this cohort were never identified as victims of abuse. IPV identification was associated with the day of a police incident, transportation by police, self-disclosure of "domestic assault," and chart documentation of mental health and substance abuse issues. When IPV was identified, ED staff provided legally useful documentation (86%), police contact (50%), and social worker involvement (45%), but only assessed safety in 33% of the women and referred them to victim services 25% of the time. CONCLUSION: The majority of police-identified IPV victims frequently use the ED for health care, but are unlikely to be identified or receive any intervention in that setting.

Roncero C; Rodriguez-Cintas L; Barral C; Fuste G; Daigre C; Ramos-Quiroga JA et al. Treatment adherence to treatment in substance users referred from psychiatric emergency service to outpatient treatment. Actas Espanolas de Psiquiatria 40(2): 63-69, 2012. (44 refs.)

Objectives. The main objective was to evaluate the treatment adherence of patients attended at the Psychiatric Emergency Room and referred to an Outpatient Drug Clinic. Our aim was to describe the degree of adherence and the factors related to it. Methods. A naturalistic study was conducted through examination of the clinical records of the patients attended in the Psychiatric Emergency Room of our hospital during one year (n=5052). Inclusion criteria consisted of substance dependence meeting DSM-IV criteria, belonging to our district, referral when discharged to an Outpatient Drug Clinic, and absence of previous treatment for Drug Addiction follow-ups (n=72). We evaluated further to the center link, adherence to the deviceduring the next year. Results. 33.4% of the patients referred to an Outpatient Drug Clinic didn't request for a visit. From those who requested a first appointment, 20.83% didn't attend. From those who attended the first appointment, 47.37% abandoned treatment in the first 12 months. No differences between substance of use or time of the year of referral were observed. Discussion. Independently to the accessibility to the Outpatient Clinic, difficulties in the adherence to drug addiction treatment exist. Initial adherence to drug addiction treatment is medium. Patient's attendance to the clinics are important due to it's relation with retention doubling. Efforts should be made to improve the compliance with pharmacologic and nonpharmacologic treatment.

Sener S; Eken C; Schultz CH; Serinken M; Ozsarac M. Ketamine with and without midazolam for emergency department sedation in adults: A randomized controlled trial. Annals of Emergency Medicine 57(2): 109-114, 2011. (17 refs.)

Study objective: We assess whether midazolam reduces recovery agitation after ketamine administration in adult emergency department (ED) patients and also compared the incidence of adverse events (recovery agitation, respiratory, and nausea/vomiting) by the intravenous (IV) versus intramuscular (IM) route. Methods: This prospective, double-blind, placebo-controlled, 2x2 factorial trial randomized consecutive ED patients aged 18 to 50 years to 4 groups: receiving either 0.03 mg/kg IV midazolam or placebo, and with ketamine administered either 1.5 mg/kg IV or 4 mg/kg IM. Adverse events and sedation characteristics were recorded. Results: Of the 182 subjects, recovery agitation was less common in the midazolam cohorts (8% versus 25%; difference 17%; 95% confidence interval [CI] 6% to 28%; number needed to treat 6). When IV versus IM routes were compared, the incidences of adverse events were similar (recovery agitation 13% versus 17%, difference 4%, 95% CI -8% to 16%; respiratory events 0% versus 0%, difference 0%, 95% CI -2% to 2%; nausea/vomiting 28% versus 34%, difference 6%, 95% CI -8% to 20%). Conclusion: Coadministered midazolam significantly reduces the incidence of recovery agitation after ketamine procedural sedation and analgesia in ED adults (number needed to treat 6). Adverse events occur at similar frequency by the IV or IM routes.

Shafiei T; Gaynor N; Farrell G. The characteristics, management and outcomes of people identified with mental health issues in an emergency department, Melbourne, Australia. Journal of Psychiatric and Mental Health Nursing 18(1): 9-16, 2011. (28 refs.)

Accessible summary The number of people with mental health problems presenting to Australian emergency departments (ED) is increasing as a result of the integration of psychiatric services with general health services. Information on all adults aged 18-65 years old who attended an ED over 2 months with an ED discharge diagnosis of a mental health diagnosis was collected. Mental health patients who were intoxicated, those who arrived after hours, or patients admitted to a mental health ward were more likely to stay longer than 8 h in the ED. Overall, mental health patients were likely to stay longer than 8 h in the ED compared with non-mental health patients. Abstract Although the number of mental health presentations to emergency departments is increasing as a result of the integration of psychiatric services with general services, few studies have explored the characteristics of mental health patients presenting to emergency departments in Australia. This study investigated the characteristics of, and outcomes in relation to, people presenting with a mental health problem to one large metropolitan emergency department. Data were collected from the emergency department's electronic records system for adult patients aged 18-65 years old with an emergency department discharge diagnosis of a mental health disorder, including substance abuse and psychosocial crisis, for two months. Mental health patients totalled 5.3% (n = 290) of adult presentations to the emergency department. Over half were male; mean age 37.4 years; 49% were allocated triage category 3/urgent; 45% arrived by ambulance; 39% were overdosed/intoxicated and 55% received one or more diagnostic investigations. Patients who were intoxicated, those who arrived after hours, or patients admitted to a mental health ward were more likely to wait longer than 8 h. Findings are broadly in line with that reported for other Australian studies, although the present findings suggest that patients had significantly more routine investigations and there were higher rates of presentations for 'intoxication'.

Shy BD; Portelli I; Nelson LS. Emergency medicine residents' use of psychostimulants and sedatives to aid in shift work. American Journal of Emergency Medicine 29(9): 1034-U342, 2011. (20 refs.)

Objectives: We evaluated the frequency that emergency medicine house staff report use of stimulants and sedatives to aid in shift work and circadian transitions. Methods: We surveyed residents from 12 regional emergency medicine programs inviting them to complete a voluntary, anonymous electronic questionnaire regarding their use of stimulants and sedatives. Results: Out of 485 eligible residents invited to participate in the survey, 226 responded (47% response frequency). The reported use of prescription stimulants for shift work is uncommon (3.1% of respondents.) In contrast, 201 residents (89%) report use of caffeine during night shifts, including 118 residents (52%) who use this substance every night shift. Eighty-six residents (38%) reported using sedative agents to sleep following shift work with the most common agents being anti-histamines (31%), nonbenzodiazepine hypnotics such as zolpidem (14%), melatonin (10%), and benzodiazepines (9%). Conclusion: Emergency medicine residents report substantial use of several classes of hypnotics to aid in shift work. Despite anecdotal reports, use of prescription stimulants appears rare, and is notably less common than use of sedatives and non-prescription stimulants.

Sims C; Sabra D; Bergey MR; Grill E; Sarani B; Pascual J et al. Detecting intimate partner violence: More than trauma team education is needed. Journal of the American College of Surgeons 212(5): 867-872, 2011. (31 refs.)

BACKGROUND: Intimate partner violence (IPV) is an underappreciated cause of morbidity and mortality in female trauma patients. We investigated the impact of a domestic violence education program for trauma residents on the detection of IPV. STUDY DESIGN: In January 2008, an educational IPV program was implemented for all trauma residents. A retrospective review of all female patients evaluated by the trauma service before and after institution of the IPV program was performed. Medical records were reviewed for demographic data, injury mechanism, social habits, and IPV documentation. Chi-square and Fisher's exact tests were used to compare patients before and after institution of the educational IPV program. RESULTS: The records of 645 female trauma patients evaluated in 2007 and 2008 were reviewed. Patients were not routinely asked about IPV, despite implementation of the educational program; 39.9% were asked about IPV in 2007 versus 46.1% in 2008 (p = 0.11). The positive disclosure of IPV did not increase from 2007 to 2008 (20.1% versus 21.2%; p = 0.83). Documentation about social habits increased considerably. In 2008, patients were asked more regularly about alcohol (71.8% versus 80.8%; p = 0.01), drugs (64.1% versus 73.7%; p = 0.01), and tobacco use (67.0% versus 78.1%; p = 0.002). Importantly, patients with documented IPV (n = 57) frequently presented to the trauma team with nonviolent mechanisms of injury (n = 30, 52.6%). CONCLUSIONS: IPV is a frequent finding in female trauma patients. Despite increased education, questions about IPV are not documented routinely. In addition, screening at-risk patients by mechanism will underestimate the prevalence of IPV. Universal screening should be mandated to increase IPV detection and enhance opportunities for intervention.

Smith PM. Tobacco use among emergency department patients. International Journal of Environmental Research and Public Health 8(1): 253-263, 2011. (20 refs.)

This is the first study to systematically track the tobacco use prevalence in an entire emergency department (ED) population and compare age-stratified rates to the general population using national, provincial, and regional comparisons. A tobacco use question was integrated into the ED electronic registration process from 2007 to 2010 in 11 northern hospitals (10 rural, 1 urban). Results showed that tobacco use documentation (85-89%) and tobacco use (26-27%) were consistent across years with the only discrepancy being higher tobacco prevalence in 2007 (32%) due to higher rates at the urban hospital. Age-stratified outcomes showed that tobacco use remained high up to 50 years old (36%); rates began to decrease for patients in their 50's (26%) and 60's (16%), and decreased substantially after age 70 (5%). The age-stratified ED tobacco rates were almost double those of the general population nationally and provincially for all but the oldest age groups but were virtually identical to regional rates. The tobacco use tracking and age-stratified general population comparisons in this study improves on previous attempts to document prevalence in the ED population, and at a more local level, provides a "big picture" overview that highlights the magnitude of the tobacco-use problem in these communities.

Suffoletto B; Callaway C; Kristan J; Kraemer K; Clark DB. Text-message-based drinking assessments and brief interventions for young adults discharged from the emergency department. Alcoholism: Clinical and Experimental Research 36(3): 552-560, 2012. (36 refs.)

Background: Brief interventions have the potential to reduce heavy drinking in young adults who present to the emergency department (ED), but require time and resources rarely available. Text-messaging (TM) may provide an effective way to collect drinking data from young adults after ED discharge as well as to provide immediate feedback and ongoing support for behavior change. The feasibility of screening young adults in the ED, recruiting them for a TM-based interventional trial, collecting weekly drinking data through TM, and the variance in drinking outcomes remains unknown. Methods: Young adults in 3 urban EDs (n = 45; aged 18 to 24 years, 54% women) identified as hazardous drinkers by the Alcohol Use Disorders Identification Test-Consumption score were randomly assigned to weekly TM-based feedback with goal setting (Intervention), weekly TMbased drinking assessments without feedback (Assessment), or control. Participants in the Intervention group who reported 5 (for men) and 4 (for women) maximum drinks during any one 24-hour period were asked whether they would set a goal to reduce their drinking the following week. We describe the interaction with TM and goal setting. We also describe the heavy drinking days (HDDs), drinks per drinking day (DPDD) using timeline follow-back procedure at baseline and 3 months. Results: We screened 109 young adults over 157 hours across 24 unique days and 52 (48%; 95% CI 38 to 50) screened positive for hazardous drinking. Of these, 45 (87%; 95% CI 74 to 94) met inclusion criteria, were enrolled and randomized, and 6 (13%; 95% CI 5 to 27) did not complete 3-month web-based follow-up; 88% (95% CI 84 to 91) of weekly TM-based drinking assessments were answered, with 77% (95% CI 58 to 90) of participants responding to all 12 weeks. Agreeing to set a goal was associated with a repeat HDD 36% (95% CI 17 to 55) of the time compared with 63% (95% CI 44 to 81) when not willing to set a goal. At 3 months, participants that were exposed to the TM-based intervention had 3.4 (SD 5.4) fewer HDDs in the last month and 2.1 (SD 1.5) fewer DPDD when compared to baseline. Conclusions: TM can be used to assess drinking in young adults and can deliver brief interventions to young adults discharged from the ED. TM-based interventions have the potential to reduce heavy drinking among young adults but larger studies are needed to establish efficacy.

Teeuw AH; Derkx BHF; Koster WA; van Rijn RR. Educational paper. Detection of child abuse and neglect at the emergency room. (review). European Journal of Pediatrics 171(6): 877-885, 2012. (102 refs.)

The emergency room (ER) represents the main system entry for crises-based health care visits. It is estimated that 2% to 10% of children visiting the ER are victims of child abuse and neglect (CAN). Therefore, ER personnel may be the first hospital contact and opportunity for CAN victims to be recognised. Early diagnosis of CAN is important, as without early identification and intervention, about one in three children will suffer subsequent abuse. This educational paper provides the reader with an up-to-date and in-depth overview of the current screening methods for CAN at the ER. Conclusion: We believe that a combined approach, using a checklist with risk factors for CAN, a structured clinical assessment and inspection of the undressed patient (called 'top-toe' inspection) and a system of standard referral of all children from parents who attend the ER because of alcohol or drugs intoxication, severe psychiatric disorders or with injuries due to intimate partner violence, is the most promising procedure for the early diagnosis of CAN in the ER setting.

Thornley S; Kool B; Robinson E; Marshall R; Smith GS; Ameratunga S. Alcohol and risk of admission to hospital for unintentional cutting or piercing injuries at home: A population-based case-crossover study. BMC Public Health 11: e-article 852, 2011. (58 refs.)

Background: Cutting and piercing injuries are among the leading causes of unintentional injury morbidity in developed countries. In New Zealand, cutting and piercing are second only to falls as the most frequent cause of unintentional home injuries resulting in admissions to hospital among people aged 20 to 64 years. Alcohol intake is known to be associated with many other types of injury. We used a case-crossover study to investigate the role of acute alcohol use (i.e., drinking during the previous 6 h) in unintentional cutting or piercing injuries at home. Methods: A population-based case-crossover study was conducted. We identified all people aged 20 to 64 years, resident in one of three regions of the country (Greater Auckland, Waikato and Otago), who were admitted to public hospital within 48 h of an unintentional non-occupational cutting or piercing injury sustained at home (theirs or another's) from August 2008 to December 2009. The main exposure of interest was use of alcohol in the 6-hour period before the injury occurred and the corresponding time intervals 24 h before, and 1 week before, the injury. Other information was collected on known and potential confounders. Information was obtained during face-to-face interviews with cases, and through review of their medical charts. Results: Of the 356 participants, 71% were male, and a third sustained injuries from contact with glass. After adjustment for other paired exposures, the odds ratio for injury after consuming 1 to 3 standard drinks of alcohol during the 6-hour period before the injury (compared to the day before), compared to none, was 1.77 (95% confidence interval 0.84 to 3.74), and for four or more drinks was 8.68 (95% confidence interval 3.11 to 24.3). Smokers had higher alcohol-related risks than non-smokers. Conclusions: Alcohol consumption increases the odds of unintentional cutting or piercing injury occurring at home and this risk increases with higher levels of drinking.

Thygerson SM; Merrill RM; Cook LJ; Thomas AM. Comparison of factors influencing emergency department visits and hospitalization among drivers in work and nonwork-related motor vehicle crashes in Utah, 1999-2005. Accident Analysis and Prevention 43(1): 209-213, 2011. (20 refs.)

This study identified contributing factors in the occurrence of motor vehicle crashes (MVCs) and the severity of crashes according to work-related status in Utah. Analyses were based on probabilistically linked data involving police crash reports and hospital inpatient and emergency department (ED) records for the years 1999-2005. Of 643,647 drivers involved in crashes, 73,437 (11.4%) went to the emergency department (ED) and 4989 (0.8%) were hospitalized. Of the drivers in crashes visiting the ED, 2330 (3.2%) were working at the time of the crash and of drivers in crashes who were hospitalized, 235 (4.7%) were working at the time of the crash. There was no significant difference between those working versus not working at the time of the crash in safety belt use (82%[53,947/66,188] for ED cases and 60% [2,489/4,176] for hospitalized cases) or fatigue (4%[ 2,697/70,536] for ED cases and 9% [450/4,824] for hospitalized cases) among drivers in crashes, but there was a significant difference with respect to alcohol drinking between workers versus nonworkers (ED: 1% [31/2,237] vs. 5% [3,455/68,299], P < 0.001; hospitalized: 3% [7/228] vs. 15% [673/4,596], P < 0.001). Of those attending the ED because of a crash, workers were significantly more likely to have broken bones, bleeding wounds, or to die. Of those hospitalized because of a crash, workers were significantly less likely to have caused the crash (65% [145/223] vs. 73% [3,315/4,566], P < 0.001). Yet although those drivers who were working at the time of the crash compared with those not working were less likely to have alcohol involved or to have caused the crash, there remains room for improvement among workers with respect to these factors, as well as safety belt use and fatigue.

Ting SA; Sullivan AF; Miller I; Espinola JA; Allen MH; Camargo CA et al. Multicenter study of predictors of suicide screening in emergency departments. Academic Emergency Medicine 19(2): 239-243, 2012. (10 refs.)

Objectives: The objective was to provide estimates and predictors of screening for suicide in emergency departments (EDs). Methods: Eight geographically diverse U. S. EDs each performed chart reviews of 100 randomly selected patients, ages 18 years or older, with visits in October 2009. Trained chart abstractors collected information on patient demographics, presentation, discharge diagnosis, suicide screening, and other mental health indicators. Univariate logistic regression was used to determine factors associated with suicide screening. Results: The cohort of 800 patients had a median age of 41 years (interquartile range = 27 to 53 years) with 57% female, 16% Hispanic, 58% white, 23% black or African American, and 10% other race. Suicide screenings were documented for 39 patients (4.9%; 95% confidence interval [CI] = 3.4% to 6.4%). Of those screened, 23 (2.9% of total sample; 95% CI = 1.7% to 4.0%) were positive for suicidal ideation or behavior. Approximately 90% of those screened had documented complaints of a psychiatric nature at triage. About one-third had either documentation of alcohol abuse (33%) or intentional illegal or prescription drug misuse (36%). Conclusions: The presence of known psychiatric problems and substance use had the strongest associations with suicide screening, yet even patients presenting with these indicators were not screened for suicide. Understanding factors that currently influence suicide screening in the ED will guide the design and implementation of improved suicide screening protocols and related interventions.

Tompkins-Dobbs K; Schiefelbein J. Emergency department policies and procedures for treatment of patients abusing methamphetamine. Journal of Emergency Nursing 37(5): 437-443, 2011. (13 refs.)

An investigative descriptive research case study design was used to explore the following questions: �Do hospital emergency departments in 2 rural, 2 suburban, and urban Kansas hospitals address a patient�s drug abuse even when the presenting complaint is unrelated to drug abuse?" and "Do emergency departments in 2 rural, 2 suburban, and 2 urban Kansas hospitals have policies and procedures available to their staff that provide guidance in caring for patients addicted to methamphetamine?" Telephone survey interviews were conducted. Consistency in themes was found among rural, suburban, and urban Kansas hospital emergency departments without regard to the size and location of the facilities. Data show that policies and procedures are not available and that treatment of patients addicted to methamphetamine is inconsistent within a single facility and across facilities in the same state. Treatment of methamphetamine addicts in the absence of policies and procedures set in place by the facility is based on the individual determination of the primary care provider and is subject to individual bias or lack of knowledge

Walley AY; Paasche-Orlow M; Lee EC; Forsythe S; Chetty VK; Mitchell S et al. Acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis. Journal of Addiction Medicine 6(1): 50-56, 2012. (65 refs.)

Objective: Hospital discharge may be an opportunity to intervene among patients with substance use disorders to reduce subsequent hospital utilization. This study determined whether having a substance use disorder diagnosis was associated with subsequent acute care hospital utilization. Methods: We conducted an observational cohort study among 738 patients on a general medical service at an urban, academic, safety-net hospital. The main outcomes were rate and risk of acute care hospital utilization (emergency department visit or hospitalization) within 30 days of discharge. The main independent variable was presence of a substance use disorder primary or secondary discharge diagnosis code at the index hospitalization. Results: At discharge, 17% of subjects had a substance use disorder diagnosis. These patients had higher rates of recurrent acute care hospital utilization than patients without substance use disorder diagnoses (0.63 vs 0.32 events per subject at 30 days, P < 0.01) and increased risk of any recurrent acute care hospital utilization (33% vs 22% at 30 days, P < 0.05). In adjusted Poisson regression models, the incident rate ratio at 30 days was 1.49 (95% confidence interval, 1.12-1.98) for patients with substance use disorder diagnoses compared with those without. In subgroup analyses, higher utilization was attributable to those with drug diagnoses or a combination of drug and alcohol diagnoses, but not to those with exclusively alcohol diagnoses. Conclusions: Medical patients with substance use disorder diagnoses, specifically those with drug use-related diagnoses, have higher rates of recurrent acute care hospital utilization than those without substance use disorder diagnoses.

Walton MA; Resko S; Whiteside L; Chermack ST; Zimmerman M; Cunningham RM. Sexual risk behaviors among teens at an urban emergency department: Relationship with violent behaviors and substance use. Journal of Adolescent Health 48(3): 303-305, 2011. (10 refs.)

Purpose: Data regarding sexual risk behaviors among adolescent patients presenting to urban emergency departments (EDs) are lacking. This article describes rates and correlates of sexual risk behaviors among adolescents screened in an urban ED. Methods: During a period of 1-year, a total of 1,576 patients aged 14-18 years, self-administered a computerized survey (57.6% female, 59.3% African American). Results: Among sexually active adolescents (60%), 12% reported four or more partners; of those, 45.3% reported using a condom all the time and 14.7% reported using substances before sex. Regression analyses examined correlates of sexual risk behaviors on the basis of demographics, violence, and substance use. Males and younger teens were more likely to report condom use than females and older teens. Participants with poor grades were more likely to have had sex and used substances before sex, and were less likely to report condom use. Participants reporting dating violence were more likely to have had sex and less likely to have used condoms, whereas participants reporting peer violence and weapon carriage were more likely to report substance use before sex. Binge drinking and marijuana use were associated with all sex risk behaviors. Conclusions: The visit to an urban ED may provide an opportunity to deliver interventions to address sexual risk behaviors among adolescents.

Warrick B; Hill M; Lehr B; Mowry J; Gummin D; Anderson D et al. A review of bath salt exposures reported to six regional poison centers. (meeting abstract). Clinical Toxicology 49(6): 567, 2011. (0 refs.)

Watson C; Wilkinson J. The intensive care management of common and uncommon drugs of misuse. (review). British Journal of Hospital Medicine 72(4): 211-218, 2011. (33 refs.)

With an ever-expanding field of illicit drugs available, doctors working in the acute specialties will inevitably be involved in the management of the serious and life-threatening side effects of drug misuse, as outlined in this article.

Wood DM; Greene SL; Dargan PI. Control of mephedrone (4-methylmethcathione) in the UK appears effective in reducing presentations to the emergency department with acute toxicity related to its use. (meeting abstract). Clinical Toxicology 49(6): 522-523, 2011

Wood DM; Panayi P; Davies S; Huggett D; Collignon U; Ramsey J et al. Analysis of recreational drug samples obtained from patients presenting to a busy inner-city emergency department: A pilot study adding to knowledge on local recreational drug use. Emergency Medicine Journal 28(1): 11-13, 2011. (11 refs.)

Introduction: Routine toxicological screening is not undertaken in individuals presenting to emergency departments (ED) with acute recreational drug toxicity, because it does not usually alter an individual patient's management. Localised information on the types of recreational drugs being used is often not available. The pilot study described here looks at the analysis of presumed recreational drugs in the possession of individuals presenting to the ED with acute recreational drug toxicity. Methods: Suspected recreational drug samples were handled as controlled drugs and transported to a Home Office approved laboratory. Samples were initially categorised on the basis of their physical appearance; liquid samples were analysed by infrared spectrophotometry and non-liquid samples were analysed by gas chromatography-mass spectrometry. Results: A total of 33 (12 liquid and 21 non-liquid) samples was analysed in this pilot study. Liquid samples were shown to contain either gamma-butyrolactone or isopropyl nitrite. 19% of non-liquid samples (12% of total samples) did not contain any drugs and 23% contained legal pharmaceutical agents. Of the remaining samples, they contained both 'classic' and 'novel' recreational drugs. Only 33.3% of crystalline substances contained methamphetamine. Discussion: This pilot study has shown that analysing samples obtained in the ED can contribute to clinicians' knowledge of local drug epidemiology. Extension of this approach in areas with a high prevalence of recreational drug use, with appropriate funding, may be useful in monitoring drug trends and detecting novel emerging drugs.

Yuma-Guerrero PJ; Lawson KA; Velasquez MM; von Sternberg K; Maxson T; Garcia N. Screening, brief intervention, and referral for alcohol use in adolescents: A systematic review. (review). Pediatrics 130(1): 115-122, 2012. (53 refs.)

Background And Objective: Alcohol use by adolescents is wide-spread and is connected to a number of negative health and social outcomes. Adolescents receiving emergent care for injuries are often linked with risky use of alcohol. The trauma system has widely adopted the use of screening, brief intervention, and referral to treatment (SBIRT) for preventing alcohol-related injury recidivism and other negative outcomes. The purpose of this article is to review the evidence around SBIRT with adolescent patients in acute care settings. Methods: This article reviews 7 randomized controlled trials evaluating risky drinking interventions among adolescent patients in acute care settings. All studies took place in the emergency departments of level I trauma centers. Results: Four of the 7 studies reviewed demonstrated a significant intervention effect; however, no one intervention reduced both alcohol consumption and alcohol-related consequences. Two of these 4 studies only included patients ages 18 and older. Subgroup analyses with adolescents engaged in risky alcohol-related behaviors, conducted in 2 of the studies, showed significant intervention effects. Five studies showed positive consumption and/or consequences for all study participants regardless of condition, suggesting that an emergent injury and/or the screening process may have a protective effect. Conclusions: Based on existing evidence, it is not clear whether SBIRT is an effective approach to risky alcohol use among adolescent patients in acute care. Additional research is needed around interventions and implementation.