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CORK Bibliography: Emergency Medicine

74 citations. July 2010 to present

Prepared: September 2011

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.

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.

Baehren DF; Marco CA; Droz DE; Sinha S; Callan EM; Akpunonu P. A statewide prescription monitoring program affects emergency department prescribing behaviors. Annals of Emergency Medicine 56(1): 19-23, 2010. (27 refs.)

Study objective: Ohio recently instituted an online prescription monitoring program, the Ohio Automated Rx Reporting System (OARRS), to monitor controlled substance prescriptions within Ohio. This study is undertaken to identify the influence of OARRS data on clinical management of emergency department (ED) patients with painful conditions. Methods: This prospective quasiexperimental study was conducted at the University of Toledo Medical Center Emergency Department during June to July 2008. Eligible participants included ED patients with painful conditions. Patients with acute injuries were excluded. After clinical evaluation, and again after presentation of OARRS data, providers answered a set of questions about anticipated pain prescription for the patient. Outcome measures included changes in opioid prescription and other potential factors that influenced opioid prescription. Results: Among 179 participants, OARRS data revealed high numbers of narcotics prescriptions filled in the most recent 12 months (median 7; range 0 to 128). Numerous providers prescribed narcotics for patients (median 3 per patient; range 0 to 40). Patients had filled narcotics prescriptions at different pharmacies (mean [SD] 3.5 [4.4]). Eighteen providers are represented in the study. Four providers treated 63% (N=114) of the patients in the study. After review of the OARRS data, providers changed the clinical management in 41% (N=74) of cases. In cases of altered management, the majority (61%; N=45) resulted in fewer or no opioid medications prescribed than originally planned, whereas 39% (N=29) resulted in more opioid medication than previously planned. Conclusion: The use of data from a statewide narcotic registry frequently altered prescribing behavior for management of ED patients with complaints of nontraumatic pain.

Bernstein E; Bernstein J; Feldman J; Fernandez W; Hagan M; Mitchell P et al. The impact of screening, brief intervention and referral for treatment in emergency department patients' alcohol use: A 3-, 6-and 12-month follow-up. Alcohol and Alcoholism 45(6): 514-519, 2010. (40 refs.)

Aims: This study aims to determine the impact of Screening, Brief Intervention and Referral for Treatment (SBIRT) in reducing alcohol consumption in emergency department (ED) patients at 3, 6, and 12 months following exposure to the intervention. Methods: Patients drinking above the low-risk limits (at-risk to dependence), as defined by National Institute of Alcohol Abuse and Alcoholism (NIAAA), were recruited from 14 sites nationwide from April to August 2004. A quasi-experimental comparison group design included sequential recruitment of intervention and control patients at each site. Control patients received a written handout. The Intervention group received the handout and participated in a brief negotiated interview with direct referral for treatment if indicated. Follow-up surveys were conducted at 3, 6, and 12 months by telephone using an Interactive Voice Response (IVR) system. Results: Of the 1132 eligible patients consented and enrolled (581 control, 551 intervention), 699 (63%), 575 (52%) and 433 (38%) completed follow-up surveys via IVR at 3, 6, and 12 months, respectively. Regression analysis adjusting for the clustered sampling design and using multiple imputation procedures to account for subject attrition revealed that those receiving SBIRT reported roughly three drinks less per week than controls (B = -3.00, SE = 1.06, P < 0.05) and the level of maximum drinks per occasion was approximately three-fourths of a drink less than controls (B = -0.76, SE = 0.29, P < 0.05) at 3 months. At 6 and 12 months post-intervention, these effects had weakened considerably and were no longer statistically or substantively significant. Conclusion: SBIRT delivered by ED providers appears to have short-term effectiveness in reducing at-risk drinking, but multi-contact interventions or booster programs may be necessary to maintain long-term reductions in risky drinking.

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.

Blow FC; Walton MA; Murray R; Cunningham RM; Chermack ST; Barry KL et al. Intervention attendance among emergency department patients with alcohol- and drug-use disorders. Journal of Studies on Alcohol and Drugs 71(5): 713-719, 2010. (46 refs.)

Objective: The emergency department (ED) visit provides a window of opportunity for screening and linkage to services for innercity adults with substance-use disorders (SUDs). This article examines predictors of intervention attendance among ED patients who screen positive for an SUD (alcohol or other drug). Method: As part of a large randomized control trial, medical and injured patients (ages 19-60) in an inner-city ED completed a computerized screening survey. Based on random assignment, those screening positive for an SUD either were scheduled to attend a post-discharge intervention or received a referral brochure. Interventions (brief motivational intervention vs. case management intervention) focused on linking participants to substance-use treatment. Independent variables assessed included demographics, ED visit reason, health functioning, readiness to change, self-efficacy, and substance use. Intervention attendance (yes/no) was the dependent variable. Results: Overall, 957 (62.3% male; 58.3% African-American; M-age = 33.2 years) were randomized to interventions (brief motivational intervention/case management intervention) and are the focus of subsequent analyses. There were no differences in the pattern of predictors of intervention attendance for brief motivational intervention versus case management intervention. Bivariate analyses compared those who attended the post-ED intervention with those who did not attend. Participants who attended the intervention (50%) were significantly more likely to be older, unmarried, insured, unemployed, and in the "action" stage of change. Conclusions: The present findings highlight the relative importance of assessing and attending to readiness to change as well as demographic factors such as insurance and employment (and potentially associated barriers) in ED-based screening, brief intervention, and referral to treatment protocols.

Braden JB; Russo J; Fan MY; Edlund MJ; Martin BC; DeVries A et al. Emergency department visits among recipients of chronic opioid therapy. Archives of Internal Medicine 170(16): 1425-1432, 2010. (25 refs.)

Background: There has been an increase in overdose deaths and emergency department visits (EDVs) involving use of prescription opioids, but the association between opioid prescribing and adverse outcomes is unclear. Methods: Data were obtained from administrative claim records from Arkansas Medicaid and HealthCore commercially insured enrollees, 18 years and older, who used prescription opioids for at least 90 continuous days within a 6-month period between 2000 and 2005 and had no cancer diagnoses. Regression analysis was used to examine risk factors for EDVs and alcohol- or drug-related encounters (ADEs) in the 12 months following 90 days or more of prescribed opioids. Results: Headache, back pain, and preexisting substance use disorders were significantly associated with EDVs and ADEs. Mental health disorders were associated with EDVs in HealthCore enrollees and with ADEs in both samples. Opioid dose per day was not consistently associated with EDVs but doubled the risk of ADEs at morphine-equivalent doses over 120 mg/d. Use of short-acting Drug Enforcement Agency Schedule II opioids was associated with EDVs compared with use of non Schedule II opioids alone (relative risk range, 1.09-1.74). Use of Schedule II long-acting opioids was strongly associated with ADEs (relative risk range, 1.64-4.00). Conclusions: Use of Schedule II opioids, headache, back pain, and substance use disorders are associated with EDVs and ADEs among adults prescribed opioids for 90 days or more. It may be possible to increase the safety of chronic opioid therapy by minimizing the prescription of Schedule II opioids in these higher-risk recipients.

Broyles LM; Gordon AJ. SBIRT implementation: Moving beyond the interdisciplinary rhetoric. (editorial). Substance Abuse 31(4): 221-223, 2010. (12 refs.)

Cai R; Crane E; Poneleit K; Paulozzi L. Emergency department visits involving nonmedical use of selected prescription drugs --- United States, 2004--2008. MMWR. Morbidity and Mortality Weekly Review 59(23): 705-709, 2010. (10 refs.)

Rates of overdose deaths involving prescription drugs increased rapidly in the United States during 1999--2006. However, such mortality data do not portray the morbidity associated with prescription drug overdoses. The CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA) reviewed the most recent 5 years of available data (2004--2008) on ED visits involving the nonmedical use of prescription drugs from SAMHSA's Drug Abuse Warning Network (DAWN). This report describes the results of that review, which showed that the estimated number of ED visits for nonmedical use of opioid analgesics increased 111% during 2004--2008 (from 144,600 to 305,900 visits) and increased 29% during 2007--2008. The highest numbers of ED visits were recorded for oxycodone, hydrocodone, and methadone, all of which showed statistically significant increases during the 5-year period. By 2008 these visits matched the number of ED visits involving illicit drugs. ED visits involving such pharmaceuticals accounted for all of the growth in overall drug misuse/abuse rates during 2004--2008. Notably, results from 2008 indicate that in addition to the large increase in visits compared with 2004, peak visit rates for both opioids and benzodiazepines appear to have shifted into the 21--24 and 25--29 years age groups and away from the 30--34 and 35--44 years age groups. As late as 2006, the peak mortality rate for fatal drug overdoses involving opioid analgesics had been in the 35--54 years age group. The 5-year increase in ED visit rates reflects, in part, substantial increases in the prescribing of these classes of drugs. The increase also might reflect an increase in the rate of nonmedical use of prescription drugs per 1,000 prescriptions, as has been observed for selected opioids. In the 2008 National Survey of Drug Use and Health (NSDUH), 4.6% of persons aged �18 years reported past-year nonmedical use of prescription pain relievers, and 2.1% reported nonmedical use of tranquilizers, a category that includes benzodiazepines. In contrast to the results of this study, NSDUH results have shown no increase in self-reported rates of nonmedical use of selected pharmaceuticals since 2004. Increasing ED visit rates in the context of stable self-reported nonmedical use rates might indicate that persons seen in EDs are different from typical respondents to NSDUH; a shift toward riskier types of pain relievers and benzodiazepines, riskier modes of use, more frequent or heavier use; and/or an increased tendency to seek emergency care because of greater awareness of the serious consequences of nonmedical use of such drugs. However, changes in health-seeking behavior would not affect changes in drug-related deaths, and DAWN ED visit trends are consistent with medical examiner data from six states also tracked by DAWN (Maine, Maryland, New Hampshire, New Mexico, Utah, and Vermont). In these states, the number of nonsuicidal deaths related to benzodiazepines increased 64.2%, and the number related to opioid analgesics other than methadone increased 47.4% during 2004--2007.

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.

Cherpitel CJ; Korcha RA; Moskalewicz J; Swiatkiewicz G; Ye Y; Bond J. Screening, brief intervention, and referral to treatment (SBIRT): 12-Month outcomes of a randomized controlled clinical trial in a Polish emergency department. Alcoholism: Clinical and Experimental Research 34(11): 1922-1928, 2010. (23 refs.)

Background: A randomized controlled trial of screening, brief intervention, and referral to treatment (SBIRT) among at-risk (based on average number of drinks per week and drinks per drinking day) and dependent drinkers was conducted in an emergency department (ED) among 446 patients 18 and older in Sosnowiec, Poland. Methods: Patients were recruited over a 23-week period (4:00 pm to 12:00 midnight) and randomized to 1 of 3 conditions: screened-only (n = 147), assessed (n = 152), and intervention (n = 147). Patients in the assessed and intervention conditions were blindly reassessed via a telephone interview at 3 months, and all 3 groups were assessed at 12 months (screened-only = 92, assessed = 99, and intervention = 87). Results: No difference was found across the 3 conditions in at-risk drinking at 12 months, as the primary outcome variable, or in decrease in the number of drinks per drinking day, with all 3 groups showing a significant reduction in both. Significant declines between baseline and 12 months in secondary outcomes of the RAPS4, number of drinking days per week, and the maximum number of drinks on an occasion were seen only for the intervention condition, and in negative consequences for both the assessment and intervention conditions. Conclusions: Data suggest that improvements in drinking outcomes found in the assessment condition were not because of assessment reactivity, with both the screened and intervention conditions demonstrating greater (although nonsignificant) improvement than the assessed condition. Only those in the intervention condition showed significant improvement in all outcome variables from baseline to 12-month follow-up. Although group by time interaction effects were not found to be significant, these findings suggest that declines in drinking measures for those receiving a brief intervention can be maintained at long-term follow-up.

Choo EK; Nicolaidis C; Jenkinson RH; Cox JM; McConnell KJ. Failure of intimate partner violence screening among patients with substance use disorders. Academic Emergency Medicine 17(8): 886-889d, 2010. (10 refs.)

Objectives: This study examined the relationship between substance use disorder (SUD) and intimate partner violence (IPV) screening and management practices in the emergency department (ED). Methods: This was a retrospective cohort study of adult ED patients presenting to an urban, tertiary care teaching hospital over a 4-month period. An automated electronic data abstraction process identified consecutive patients and retrieved visit characteristics, including results of three violence screening questions, demographic data, triage acuity, time of visit, and International Classifications of Disease, 9th revision (ICD-9), diagnosis codes. Data on management were collected using a standardized abstraction tool by two reviewers masked to the study question. Multivariate logistic regression was used to determine predictors of screening and management. Results: In 10,071 visits, 6,563 violence screens were completed. IPV screening was documented in 33.5% of patients with alcohol-related diagnoses (95% confidence interval [CI] = 27.7% to 39.3%, chi 2 = 116.78, p < 0.001) and 53.3% of patients with drug-related diagnoses (95% CI = 44.3% to 62.3%, chi 2 = 7.69, p = 0.006), compared to 66.1% of patients without these diagnoses (95% CI = 65.2% to 67.1%). In the multivariate analysis, alcohol (odds ratio [OR] = 0.30, 95% CI = 0.22 to 0.40) and drug use (OR = 0.56, 95% CI = 0.38 to 0.83) were associated with decreased odds of screening. Of completed screens, 429 (6.5%) were positive, but violence was addressed further in only 55.7% of patients. Substance abuse did not appear to affect the odds of having positive screens addressed further by providers (OR = 1.96, 95% CI = 0.39 to 10.14). Conclusions: This study found an association between SUD and decreased odds of IPV screening. Failure to screen for IPV in the setting of substance use may represent a missed opportunity to address a critical health issue and be a barrier to successful intervention.

Cremonte M; Ledesma RD; Cherpitel CJ; Borges G. Psychometric properties of alcohol screening tests in the emergency department in Argentina, Mexico and the United States. Addictive Behaviors 35(9): 818-825, 2010. (45 refs.)

The objective of this article is to report psychometric characteristics of the AUDIT, CAGE, RAPS4, and TWEAK and to compare them across three countries: Argentina, Mexico, and the United States which used a similar protocol and methodology. Probability samples of patients 18 years and older were drawn from emergency departments in Mar del Plata, Argentina (n = 780), Pachuca, Mexico (n=1624) and Santa Clara, U.S. (n=1220). Concurrent validity was assessed by comparing their performance against a diagnosis of alcohol dependence (DSM-IV) obtained through the Composite International Diagnostic Interview, and for the briefer measures, also by their correlation with the AUDIT. The internal consistency of the CAGE, RAPS4, and TWEAK scores was estimated by the KR-20 formula and by Cronbach's Alpha for the AUDIT. Corrected item-total correlation and D-values were used as item discrimination measures. In Argentina and Mexico the AUDIT and the RAPS4 showed the highest validity. Reliability of all instruments was higher in the US than in Argentina or Mexico. In all three countries, reliability of the TWEAK was lowest, while the AUDIT was highest. With a few exceptions, all items showed good discrimination powers.

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.

Daube M; Jelinek GA. Smoking out tobacco: A vital preventive role for emergency departments. (editorial). Emergency Medicine Australasia 22(4): 260-262, 2010. (11 refs.)

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.

Desy PM; Howard PK; Perhats C; Li SL. Alcohol screening, brief intervention, and referral to treatment conducted by emergency nurses: An impact evaluation. Journal of Emergency Nursing 36(6): 538-545, 2010. (30 refs.)

Introduction: In a quasi-experimental study, control and intervention group outcomes were compared following implementation of alcohol screening, brief intervention, and referral to treatment (SBIRT) by emergency nurses. The primary hypothesis was: Trauma patients who participate in nurse-delivered ED SBIRT will have greater reductions in alcohol consumption and fewer alcohol-related incidents than those who do not. Methods: Patients were screened for alcohol use and those with risky drinking were randomly assigned to either the intervention or usual care group. Those in the intervention group received a brief motivational intervention and referral to appropriate follow-up services. Using medical and driving history records, subjects' alcohol consumption, alcohol-related traffic incidents, repeat injuries, and repeat ED visits were compared between groups at baseline and three-month follow-up. Results: Alcohol consumption decreased by 70% in the intervention group compared to 20% in the usual care group. Drinking frequency also decreased in both groups. Fewer patients from the intervention group (20%) had recurring ED visits compared to patients in the usual care group (31%). Discussion: The SBIRT procedure can impact alcohol consumption and potentially reduce injuries and ED visits when successfully implemented by staff nurses in the emergency department environment. Further research is needed to improve follow-up methods in this hard to reach, mobile patient population.

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.

D'Onofrio G; Degutis LC. Integrating Project ASSERT: A screening, intervention, and referral to treatment program for unhealthy alcohol and drug use into an urban emergency department. Academic Emergency Medicine 17(8): 903-911, 2010. (40 refs.)

Objectives: The objective was to evaluate the effects of Project Alcohol and Substance Abuse Services Education and Referral to Treatment (ASSERT), an emergency department (ED)-based screening, brief intervention, and referral to treatment program for unhealthy alcohol and other drug use. Methods: Health promotion advocates (HPAs) screened ED patients for alcohol and/or drug problems 7 days a week using questions embedded in a general health questionnaire. Patients with unhealthy drinking and/or drug use received a brief negotiation interview (BNI), with the goal of reducing alcohol/drug use and/or accepting a referral to a specialized treatment facility (STF), depending on severity of use. Patients referred to an STF were followed up at 1 month by phone or contact with the STF to determine referral completion and enrollment into the treatment program. Results: Over a 5-year period (December 1999 through December 2004), 22,534 adult ED patients were screened. A total of 10,246 (45.5%) reported alcohol consumption in the past 30 days, of whom 5,533 (54%) exceeded the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for low-risk drinking. Use of at least one illicit drug was reported by 3,530 patients (15.7%). Over one-fourth of screened patients received BNIs (6,266, or 27.8%). Of these, 3,968 (63%) were referred to an STF. Eighty-three percent of patients were followed at 1 month, and 2,159 (65%) had enrolled in a program. Patients who received a direct admission to an STF were 30 times more likely to enroll than those who were indirectly referred (odds ratio = 30.71; 95% confidence interval = 18.48 to 51.04). After 3 years, funding for Project ASSERT was fully incorporated into the ED budget. Conclusions: Project ASSERT has been successfully integrated into an urban ED. A direct, facilitated referral for patients with alcohol and other drug problems results in a high rate of enrollment in treatment programs.

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.

Ehrlich PF; Maio R; Drongowski R; Wagaman M; Cunningham R; Walton MA. Alcohol interventions for trauma patients are not just for adults: Justification for brief interventions for the injured adolescent at a pediatric trauma center. Journal of Trauma, Injury, Infection and Critical Care 69(1): 202-210, 2010. (39 refs.)

Background: Research on the rates of alcohol and drug misuse as well as developmentally appropriate screening and intervention approaches in a hospitalized pediatric trauma population are lacking. The purpose of this study was to identify the rate of alcohol misuse in an admitted trauma population of adolescents aged 11 years to 17 years and to identify key correlates of alcohol misuse in this population including age, gender, and injury severity. Methods: A prospective clinical study of 230 injured youth (aged 11-17 years) comprising both hospitalized and emergency department (ED) population was performed, and the patients were screened for the Alcohol Use Disorders Identification Test (AUDIT), blood alcohol levels (BALs), and drinking and driving index. The main outcome measures were rates of alcohol misuse characterized by a positive BAL or a positive AUDIT. Results: Thirty percent hospitalized trauma patients screened positive for alcohol misuse. Five patients had a positive BAL without a positive AUDIT score. Binge drinking was the most commonly positive domain of the AUDIT tool. In hospitalized trauma patients who are older than 14 years (p = 0.005), it was significantly associated with a positive AUDIT score, but the injury severity score, gender, mechanism of injury, or positive BAL were not significant predictors. In the ED sample, 15.8% of patients had a positive AUDIT score. One-way analysis of variance among the ED group showed that age >= 14 was the single predictor of a positive AUDIT score. Twenty-three percent of hospitalized patients had been in a car, where the driver had been drinking. The average AUDIT scores in this group was 5.3 versus 1.0 (p < 0.001), compared with those who had not ridden in a car with a driver who had been drinking. Conclusions: Injured youth admitted to a pediatric trauma center are a high-risk population. Alcohol misuse is a significant cofactor for trauma for these patients, and effective developmentally appropriate interventions are justified and needed.

Fatovich DM; Bartu A; Davis G; Atrie J; Daly FFS. Morbidity associated with heroin overdose presentations to an emergency department: A 10-year record linkage study. Emergency Medicine Australasia 22(3): 240-245, 2010. (23 refs.)

Introduction: To examine hospitalizations in a cohort of 224 patients who presented with non-fatal heroin overdose to an ED. Methods: A record linkage study, using the morbidity, mental health and mortality databases in the Data Linkage Unit of the Department of Health, Western Australia. The main outcome measures were hospital separations 5 years before and after entry into the cohort. Results: Before entry into the cohort, 199 (89%) patients had an admission to mental health services. These 199 had a combined total of 1367 separations, most commonly for a mental health condition, injury or poisoning. Women had more than twice the relative risk (RR) of men for all separations (RR 2.35, 95% confidence interval [CI] 1.96-2.82, P < 0.001) and for injury and poisoning separations (RR 2.04, 95% CI 1.56-2.66, P < 0.001). The highest concentrations of separations occurred within 1 year before and 1 year after entry into the cohort. There were 12 (5.4%, 95% CI 2.9-9.4%) deaths, most commonly from overdose. Conclusion: Non-fatal heroin overdose ED presentations are associated with a cluster of hospitalizations around that episode, likely to be related to heroin availability. Presentation to hospital by heroin users represents an opportunity to counsel less risky behaviour.

Ferro TN; Goslar PW; Romanovsky AA; Petersen SR. Smoking in trauma patients: The effects on the incidence of sepsis, respiratory failure, organ failure, and mortality. Journal of Trauma: Injury, Infection, and Critical Care 69(2): 308-311, 2010. (18 refs.)

Background: There is a high percentage of smokers among trauma patients. Cigarette smoking has been associated with the development of acute lung injury and the adult respiratory distress syndrome in critically ill patients. It is also known that nicotine exerts immunosuppressive and anti-inflammatory effects with chronic use. Trauma patients who are smokers usually go through acute nicotine withdrawal after the traumatic event and during their stay in ICU. How the smoking status and acute nicotine withdrawal affect outcomes after trauma is unknown. This question was addressed in this study by analyzing the incidence of sepsis, septic shock and multiple organ dysfunction syndrome, and other outcomes in smoking and nonsmoking trauma patients. Methods: A retrospective cohort of trauma patients who met the criteria was randomly selected from the trauma registry. Individual charts were reviewed to confirm documented smoking status. Criteria for selection included the following: Injury Severity Score >= 20, age 18 to 65 years, hospital length of stay >72 hours. Patients with COPD/emphysema, diabetes mellitus, cardiac disease, malignancy, pregnancy, or steroid use were excluded. Results: Overall, 327 patient charts were reviewed: 156 smokers and 171 nonsmokers. Men outnumbered women in the smoking group fourfold (p = 0.003 versus nonsmokers). Age, Injury Severity Score, the presence of shock on admission, the type of trauma (blunt or penetrating), ICU and hospital length of stay, and the duration of ventilator support were similar between smokers and nonsmokers. There were no differences in the incidence of sepsis, pneumonia, adult respiratory distress syndrome, or multiple organ dysfunction syndrome. Mortality was low (1.2% in smokers; 0.6% in nonsmokers) and did not differ significantly between the groups. Conclusions: The smoking status plays a minimal role in the outcome of healthy trauma patients. This suggests that the acute nicotine withdrawal that usually occurs in critically ill patients has no clinically significant implications after injury.

Field CA; Caetano R. The effectiveness of brief intervention among injured patients with alcohol dependence: Who benefits from brief interventions? Drug and Alcohol Dependence 111(1-2): 13-20, 2010. (60 refs.)

Background: Research investigating the differential effectiveness of Brief Motivational Interventions (BMIs) among alcohol-dependent and non-dependent patients in the medical setting is limited. Clinical guidelines suggest that BMI is most appropriate for patients with less severe alcohol problems. As a result, most studies evaluating the effectiveness of BMI have excluded patients with an indication of alcohol dependence. Methods: A randomized controlled trial of brief intervention in the trauma care setting comparing BMI to treatment as usual plus assessment (TAU+) was conducted. Alcohol dependence status was determined for 1336 patients using DSM-IV diagnostic criteria. The differential effectiveness of BMI among alcohol-dependent and non-dependent patients was determined with regard to volume per week, maximum amount consumed, percent days abstinent, alcohol problems at 6 and 12 months follow-up. In addition, the effect of BMI on dependence status at 6 and 12 months was determined. Results: There was a consistent interaction between BMI and alcohol dependence status, which indicated significantly higher reductions in volume per week at 6 and 12 months follow-up (beta = -.56, p = .03, beta = -.63, p = .02, respectively), maximum amount at 6 months (beta = -.31, p = .04), and significant decreases in percent days abstinent at 12 months (beta = .11, p = .007) and alcohol problems at 12 months (beta = -2.7, p(12) = .04) among patients with alcohol dependence receiving BMI. In addition, patients with alcohol dependence at baseline that received BMI were .59 (95% CI = .39-.91) times less likely to meet criteria for alcohol dependence at six months. Conclusions: These findings suggest that BMI is more beneficial among patients with alcohol dependence who screen positive for an alcohol-related injury.

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.

Gray S; Borgundvaag B; Sirvastava A; Randall I; Kahan M. Feasibility and reliability of the SHOT: A short scale for measuring pretreatment severity of alcohol withdrawal in the emergency department. Academic Emergency Medicine 17(10): 1048-1054, 2010. (19 refs.)

Background: Use of a symptom-triggered scale to measure the severity of alcohol withdrawal could reduce the rate of seizures and other complications. The current standard scale, the Clinical Institute of Withdrawal Assessment (CIWA), takes a mean (+/- SD) of 5 minutes to complete, requiring 30 minutes of nursing time per patient when multiple measures are required. Objectives: The objective was to assess the feasibility and reliability of a brief scale of alcohol withdrawal severity. Methods: The SHOT is a brief scale designed to assess alcohol withdrawal in the emergency department (ED). It includes four items: sweating, hallucinations, orientation, and tremor (SHOT). It was developed based on a literature review and a consensus process by emergency and addiction physicians. The SHOT was first piloted in one ED, and then a prospective observational study was conducted at a different ED to measure its feasibility and reliability. Subjects included patients who were in alcohol withdrawal. One nurse administered the SHOT and CIWA, and the physician repeated the SHOT independently. The SHOT was done only at baseline, before treatment was administered. Results: In the pilot study (12 patients), the SHOT took 1 minute to complete on average, and the CIWA took 5 minutes. Sixty-one patients participated in the prospective study. For the SHOT and the CIWA done by the same nurse, the kappa was 0.88 (95% confidence interval [CI] = 0.52 to 1.0; p < 0.0001), and the Pearson's r was 0.71 (p < 0.001). The kappa for the nurse's CIWA score and the physician's SHOT score was 0.61 (95% CI = 0.25 to 0.97; p < 0.0006), and the Pearson's r was 0.48 (p = 0.002). The SHOTs performed by the nurse and physician agreed on the need for benzodiazepine treatment in 30 of 37 cases (82% agreement, kappa = 0.35, 95% CI = 0.03 to 0.67; p < 0.02). The mean (+/- SD) time taken by nurses and physicians to complete the SHOT was 1 (+/- 0.52) minute (median = 0.6 minutes). Seventeen percent of patients scored positive on the SHOT for hallucinations or disorientation. Conclusions: The SHOT has potential as a feasible and acceptable tool for measuring pretreatment alcohol withdrawal severity in the ED. Further research is needed to validate the SHOT, to assess the utility of serial measurements of the SHOT, and to demonstrate that its use reduces length of stay and improves clinical outcomes.

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.

Grunau BE; Wiens MO; Greidanus M. Dantrolene for the treatment of MDMA toxicity. Canadian Journal of Emergency Medicine 12(5): 457-459, 2010. (11 refs.)

MDMA (3,4-methylenedioxymethamphetamine), popularly known as "Ecstasy," was first introduced and patented by Merck & Co., Inc., in 1914 as an appetite suppressant. Currently, its primary role is as an illegal stimulant used to produce a euphoric effect during parties. This case report de scribes a 31-year-old man who, after taking 3 tablets of Ecstasy, presented to an emergency department with a decreased level of consciousness and became progressively hyperthermic and rigid. During the course of his acute illness, his temperature reached 42.2 degrees C rectally. He was given mechanical ventilation. He was aggressively cooled and dantrolene was initiated. Soon after the administration of dantrolene his temperature decreased and his rigidity began to resolve. The only complication was rhabdomyolysis with a creatine kinase level increasing to over 150 mu kat/L. This did not progress to acute renal failure. The patient made a full recovery and was discharged to psychiatry for assessment.

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.

Hendrickson RG; Cloutier RL; Fu RW. The association of controlling pseudoephedrine availability on methamphetamine-related emergency department visits. Academic Emergency Medicine 17(11): 1216-1222, 2010. (23 refs.)

Objectives: Methamphetamine is a drug of abuse that has been manufactured locally by chemical conversion from the decongestant pseudoephedrine. In July 2006, an Oregon state law was enacted to establish pseudoephedrine as a schedule III drug and make it available by prescription only. This study sought to determine if this legislation altered the number of emergency department (ED) visits that are related to methamphetamine use. Methods: This was a retrospective analysis of a database created during a prospective study aimed at determining the effect of methamphetamine on ED visits. That prospective study was 1 year in duration and required ED clinicians to determine whether a patient's visit was related to methamphetamine and if the patient had confirmed use of methamphetamine. The clinicians received initial and continued education and training on methamphetamine during the study period. The questions were asked at every ED visit during the study period and were electronically linked to the patient's disposition and could not be circumvented. The study period was divided into prelegislation (February 5, 2006, to June 30, 2006) and postlegislation periods (July 1, 2006, to February 5, 2007). Results: Over the 1-year study period, 37,625 patients were enrolled, 1.90% (n = 714) of patients had methamphetamine-related ED visits (MREDVs), and 1.65% (n = 620) had confirmed methamphetamine use. Patients with MREDVs were more likely than patients with non-MREDVs to be white and uninsured. The number and proportion of weekly MREDVs significantly decreased from the prelegislation period to the postlegislation period (mean number of weekly visits, 18.0 vs. 11.3, p = 0.001; mean proportion of weekly visits, 2.3% vs. 1.6%, p = 0.003). The number and proportion of weekly confirmed users of methamphetamine also significantly decreased during the study period (mean number of weekly users, 14.6 vs. 10.3, p = 0.004; mean proportion of weekly users, 1.9% vs. 1.4%, p = 0.017). There were no significant differences in the diagnoses of MREDVS between the pre- and postlegislation periods. Conclusions: This study found an association between the enactment of legislation that limits pseudoephedrine availability and a decrease in MREDVs and confirmed users of methamphetamine in the study ED.

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.

Lee CS; Baird J; Longabaugh R; Nirenberg TD; Mello MJ; Woolard R. Change plan as an active ingredient of brief motivational interventions for reducing negative consequences of drinking in hazardous drinking emergency-department patients. Journal of Studies on Alcohol and Drugs 71(5): 726-733, 2010. (44 refs.)

Objective: Few studies have examined the effects of brief motivational intervention components, such as change-plan completion, on treatment outcomes. This secondary analysis of an opportunistically recruited emergency-department sample of hazardous injured drinkers examines the potential predictive role of an alcohol-related change plan on treatment outcomes after accounting for pretreatment readiness. Written change plans were independently rated. Method: A mediational analysis framework tested directional hypotheses between pretreatment readiness, change plan, and treatment outcomes using linear regressions. The baseline total Drinker Inventory of Consequences (DrInC) score was covaried on 12-month DrInC total score, in all analyses. Participants who completed a brief motivational intervention and a change plan were included (N = 333). Results: Pretreatment readiness was negatively associated with alcohol consequences at 12 months, beta = -.09, t(254) = -2.07, p < .05, and good-quality change plans, beta = .18, t(320) = 4.37, p < .001. With change plan and readiness in the same model, the relationship between readiness and treatment outcomes became nonsignificant, but change plan remained a significant predictor of treatment outcomes in the expected direction, beta = -.17, t(254) = -2.89, p < .01. Follow-up generalized linear modeling including an interaction term (change plan and pretreatment readiness) revealed that those with high readiness and a good-quality change plan versus those with low readiness and a poor-quality change plan had better-than-predicted outcomes for either readiness or change plan alone. Conclusions: Study findings suggest that the change plan in brief motivational intervention may be an active ingredient of treatment associated with better outcomes over and above the influence of pretreatment readiness.

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.

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.

Lowe RA; Fu RW; Gallia CA. Impact of policy changes on emergency department use by medicaid enrollees in Oregon. Medical Care 48(7): 619-627, 2010. (30 refs.)

Objective: In 2003, Oregon's Medicaid expansion program, the Oregon Health Plan (OHP), implemented premiums and copayments and eliminated outpatient behavioral health services. We ascertained whether these changes, including $50 copayments for emergency department (ED) visits, affected ED use. Methods: This study used statewide administrative data on 414,009 adult OHP enrollees to compare ED utilization rates (adjusted for patient characteristics) in 3 time periods: (1) before the cutbacks, (2) after the cutbacks, and (3) after partial restoration of benefits. We examined overall ED visits and several subsets of ED visits: visits requiring hospital admission, injury-related, drug-related, alcohol-related, and other psychiatric visits. Because the policy changes affected only the expansion program (OHP Standard), we ascertained the impact of these changes compared with a control group of categorically eligible Medicaid enrollees (OHP Plus). Results: Compared with the control group, case-mix-adjusted ED utilization rates fell 18% among OHP Standard enrollees after the cutbacks. The rate of ED visits leading to hospitalization fell 24%. Injury-related visits and psychiatric visits excluding chemical dependency exhibited a similar pattern to overall ED visits. Drug-related ED visits increased 32% in the control group, perhaps reflecting the closure of drug treatment programs after the cutbacks reduced their revenue. Conclusion: The policy changes were followed by a substantial reduction in ED use. That ED visits requiring hospital admission fell to about the same extent as overall ED use suggests that OHP enrollees may have been discouraged from using EDs for emergencies as well as less-serious problems.

Lucidarme O; Seguin A; Daubin C; Ramakers M; Terzi N; Beck P et al. Nicotine withdrawal and agitation in ventilated critically ill patients. Critical Care 14(2): r58, 2010. (41 refs.)

Introduction: Smoking is highly addictive, and nicotine abstinence is associated with withdrawal syndrome in hospitalized patients. In this study, we aimed to evaluate the impact of sudden nicotine abstinence on the development of agitation and delirium, and on morbidities and outcomes in critically ill patients who required respiratory support, either noninvasive ventilation or intubation, and mechanical ventilation. Methods: We conducted a prospective, observational study in two intensive care units (ICUs). The 144 consecutive patients admitted to ICUs and requiring mechanical ventilation for > 48 hours were included. Smoking status was assessed at ICU admission by using the Fagerstrom Test of Nicotine Dependence (FTND). Agitation, with the Sedation-Agitation Scale (SAS), and delirium, with the Intensive Care Delirium Screening Checklist (ICDSC), were tested twice daily during the ICU stay. Agitation and delirium were defined by SAS > 4 and ICDSC > 4, respectively. Nosocomial complications and outcomes were evaluated. Results: Smokers (n = 44) were younger and more frequently male and were more likely to have a history of alcoholism and to have septic shock as the reason for ICU admission than were nonsmokers. The incidence of agitation, but not delirium, increased significantly in the smoker group (64% versus 32%; P = 0.0005). Nicotine abstinence was associated with higher incidences of self-removal of tubes and catheters, and with more interventions, including the need for supplemental sedatives, analgesics, neuroleptics, and physical restraints. Sedation-free days, ventilator-free days, length of stay, and mortality in ICUs did not differ between groups. Multivariate analysis identified active smoking (OR, 3.13; 95% CI, 1.45-6.74; P = 0.003) as an independent risk factor for agitation. Based on a subgroup of 56 patients, analysis of 28 pairs of patients (smokers and nonsmokers in a 1:1 ratio) matched for age, gender, and alcoholism status found similar results regarding the role of nicotine withdrawal in increasing the risk of agitation during an ICU stay. Conclusions: Nicotine withdrawal was associated with agitation and higher morbidities in critically ill patients. These results suggest the need to look specifically at those patients with tobacco dependency by using the FTND in ICU settings. Identifying patients at risk of behavioral disorders may lead to earlier interventions in routine clinical practice.

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.

Lynch A; Quigley P. ExHALED Study: Prevalence of smoking and harm levels in an emergency department cohort. Emergency Medicine Australasia 22(4): 287-295, 2010. (41 refs.)

Objective: To determine the prevalence of smoking among ED patients compared with the general New Zealand (NZ) smoking prevalence. Secondary outcomes were to determine smokers' level of nicotine dependence, readiness to quit and engagement with primary health care. Methods: This was a prospective, cross-sectional prevalence study of ED patients seen consecutively over 6 days in Wellington Hospital, Wellington South, NZ. Medically stable patients >= 18 years were asked about their smoking habits by a closed-question survey. Results: Five hundred and twenty-eight patients comprised the study group. The ED smoking prevalence was 33.1% and higher than the general NZ smoking prevalence of 20.7%. Of those who smoked, 26.3% were 'moderately' to 'very highly' dependent on nicotine (Fagerstrom Test for Nicotine Dependence, FTND score >= 5). Of those who smoked, 74.9% stated they wanted to quit, 42.9% wanted to quit within the next month and 60.6% wanted an ED quit smoking pack. There were 13.6% of ED patients not registered with a general practitioner; of this, 61.1% were current smokers and 70.5% wanted to quit smoking. Conclusions: The prevalence rates of smoking are higher among patients attending Wellington Hospital ED than the general NZ population and the majority would like to quit smoking. One in four ED smokers have a high FTND score and are considered nicotine-dependent. Many patients who were not registered with a general practitioner smoked, and the majority wanted to quit. Finally, there is significant interest from ED patients in receiving quit smoking packs from the ED.

MacLeod JBA; Hungerford DW. Alcohol-related injury visits: Do we know the true prevalence in US trauma centres? Injury 41(7): 847-851, 2010. (37 refs.)

Introduction: Alcohol consumption is a significant risk factor for injuries. Further, level I trauma centres are mandated to screen and provide a brief intervention for identified problem drinkers. However, a valid population-based estimate of the magnitude of the problem is unknown. Therefore, the goal of this study is to evaluate the extent to which the present literature provides a valid estimate of the prevalence of alcohol-related visits to U.S. trauma centres. Methods: A Medline search for all articles from 1966 to 2007 that might provide prevalence estimates of alcohol-related visits to U.S. trauma centres yielded 836 articles in English language journals. This review included only papers whose main or secondary goal was to estimate the prevalence of positive blood alcohol concentration (BAC) or acute intoxication. Both a crude aggregate estimate and sample size adjusted estimate were calculated from the included papers and the coverage and comparability of methods were evaluated. Results: Of the 15 studies that met inclusion criteria, incidence estimates of alcohol-related visits ranged from 26.2% to 62.5% and yielded an aggregate, weighted estimate of 32.5%. Target population, capture rate, and threshold for a positive screening result varied considerably across studies. No study provided a comprehensive estimate, i.e., of all trauma patients hospitalised, treated and released, or who died. Conclusions: Although the incidence of alcohol-related visits to U.S. trauma centres appears very high perhaps higher than any other medical setting, the validity of our aggregate estimate is threatened by crucial methodological considerations. The lack of a methodologically valid prevalence estimate hinders efforts to devise appropriate policies for trauma centres and across medical settings.

Mahabee-Gittens EM; Vaughn L; Gordon JS. Youths' and parents' views on the acceptability and design of a video-based tobacco prevention intervention. Journal of Child & Adolescent Substance Abuse 19(5): 391-405, 2010. (55 refs.)

The purpose of this study was to evaluate the acceptability of a brief, video-based parental intervention that modeled parent-child communication about tobacco, delivered within an emergency department (ED) setting. While waiting to be seen by a physician in the ED, 20 parent-youth dyads watched the video together and then private, semi-structured focused interviews were conducted around the take-home message and views on the settings, actors, and content of the videos. Dyads agreed that the design, delivery, and content of the video intervention were acceptable, realistic, and useful in providing parental reinforcements about the importance of parent-youth tobacco communication, and the ED was considered to be a good setting for watching the video. Findings support the development and delivery of such an ED intervention and aids in determining content and scenarios for future intervention development.

Manchikanti L; Fellows B; Ailinani H; Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: A ten-year perspective. (review). Pain Physician 13(5): 401-435, 2010. (295 refs.)

The treatment of chronic pain, therapeutic opioid use and abuse, and the nonmedical use of prescription drugs have been topics of intense focus and debate. After the liberalization of laws governing opioid prescribing for the treatment of chronic non-cancer pain by state medical boards in the late 1990s, and with the introduction of new pain management standards implemented by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2000, opioids, in general, and the most potent forms of opioids including Schedule II drugs, in particular, have dramatically increased. Despite the escalating use and abuse of therapeutic opioids, nearly 15 to 20 years later the scientific evidence for the effectiveness of opioids for chronic non-cancer pain remains unclear. Concerns continue regarding efficacy; problematic physiologic effects such as hyperalgesia, hypogonadism and sexual dysfunction; and adverse side effects especially the potential for misuse and abuse and the increase in opioid-related deaths. Americans, constituting only 4.6% of the world's population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world's illegal drugs. Retail sales of commonly used opioid medications (including methadone, oxycodone, fentanyl base, hydromorphone, hydrocodone, morphine, meperidine, and codeine) have increased from a total of 50.7 million grams in 1997 to 126.5 million grams in 2007. This is an overall increase of 149% with increases ranging from 222% for morphine, 280% for hydrocodone, 319% for hydromorphone, 525% for fentanyl base, 866% for oxycodone, to 1,293% for methadone. Average sales of opioids per person have increased from 74 milligrams in 1997 to 369 milligrams in 2007, a 402% increase. Surveys of nonprescription drug abuse, emergency department visits for prescription controlled drugs, unintentional deaths due to prescription controlled substances, therapeutic use of opioids, and opioid abuse have been steadily rising. This manuscript provides an updated 10-year perspective on therapeutic use, abuse, and nonmedical use of opioids and their consequences.

Martin ND; Grabo DJ; Tang LL; Sullivan J; Kaulback KR; Weinstein MS et al. Are roadside pedestrian injury patterns predictable in a densely populated, urban setting? Journal of Surgical Research 163(2): 323-326, 2010. (13 refs.)

Background. Roadside pedestrian injuries represent a significant portion of trauma team activations, especially at urban trauma centers. Patient demo-graphics and severity of injury vary greatly in this patient population. Herein, we hypothesize that injury patterns may be predictable, especially with respect to age. Materials and Methods. All patients with roadside pedestrian injuries evaluated at our urban, level one trauma center from January 2006 through December 2008 were retrospectively reviewed. Data were collected from the institutional trauma registry. Age was used as an independent variable and compared with injury type, substance abuse, discharge setting, and mortality. Results. There were 226 roadside pedestrian injuries during the study period. Patients were divided into groups according to age, under 20 y, 21-40 y, 4165 y, and over 65 y. Head injuries were more prevalent in patients over age 65, 30.4% versus 14.0% (P = 0.05). There was a trend for increasing alcohol use in the younger population. The likelihood of discharge to a rehab facility increased with age, 0%, 11.8%, 38.2%, 50.0%, respectively (P < 0.001). Mortality was significantly higher in patients older than 65 y, 15.2% versus 3.3% (P = 0.049). Conclusions. Roadside pedestrian injuries have predictable injury patterns based on age. Older patients are more likely to have a head injury, longer length of stay, need for a rehab stay, and have a higher mortality. Further studies are needed to correlate precise injuries with collision mechanism and evaluate specific risk factors in this high risk population.

Marx WH. Smoking in trauma patients: The effects on the incidence of sepsis, respiratory failure, organ failure, and mortality (comment). Journal of Trauma: Injury, Infection, and Critical Care 69(2): 311-312, 2010. (5 refs.)

Mascola L; Dassey D; Fogleman S; Paulozzi L; Reed CG. Ecstasy overdoses at a New Year's Eve rave --- Los Angeles, California, 2010. MMWR. Morbidity and Mortality Weekly Review 59(22): 677-681, 2010. (10 refs.)

Ecstasy (3,4-methylenedioxymethamphetamine [MDMA]) is an illegal synthetic amphetamine used as a stimulant and hallucinogen (1--3). On January 4, 2010, the Los Angeles County (LAC) Department of Public Health (DPH) learned of six MDMA-related emergency department (ED) visits and one death, all linked to a New Year's Eve event attended by approximately 45,000 persons. LAC DPH conducted an investigation to search for additional MDMA-related ED visits, characterize the cases, and determine whether drug contamination was involved. This report summarizes the results of the investigation, which determined that 18 patients visited EDs in LAC for MDMA-related illness within 12 hours of the rave. All were aged 16--34 years, and nine were female. In addition to using MDMA, 10 of the 18 had used alcohol, and five had used other drugs. Three patients were admitted to the hospital, including one to intensive care. A tablet obtained from one of the patients contained MDMA and caffeine, without known toxic contaminants. The cluster of apparent ecstasy overdoses occurred in the context of likely increasing MDMA use in the county during 2005--2009, as indicated by increased identification of MDMA-containing forensic specimens and a large increase in LAC residents entering drug treatment programs for MDMA. Collaboration between public health, police, fire, and emergency medical service (EMS) officials on a comprehensive prevention strategy might reduce the number of overdoses at similar events

Public Domain

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.

Mclaughlin M. Alcohol-associated illness and injury and ambulance calls in a midwestern college town: A four-year retrospective analysis. Prehospital Emergency Care 14(4): 485-490, 2010. (9 refs.)

Background. Alcohol is often a factor in illness and injury among college-aged individuals. Ambulance services responding to 9-1-1 calls in college towns regularly encounter patients who have consumed alcohol to the point of intoxication and subsequently suffered an injury or experienced an illness necessitating prehospital emergency care. Objectives. The first objective was to review ambulance calls in a Midwestern college town in order to identify patterns or trends related to alcohol consumption. Another objective was to determine to what extent, if any, underage drinking was a factor in these calls. A final objective was to determine whether there were types of illness or injuries related to 9-1-1 calls that were involved with alcohol consumption among college-aged students. Methods. This was a retrospective study using secondary data of four years of ambulance calls that occurred in a specific geographic region of a college town. All patient care reports (PCRs) included alcohol consumption as a pertinent factor in the call. Data were de-identified and in some cases aggregated to ensure confidentiality. Descriptive statistics were used to identify prevalence and incidence of injury and illness and patient demographics. Results. Of the ambulance calls for service in the geographic area, 44.4% to 45.8% identified as "downtown" had alcohol consumption as a reported factor in the PCR. The number of calls for service that involved patients below the legal drinking age (21 years) was small but increased between 2004 and 2007. Calls involving male patients made up the majority of calls with alcohol as a factor. The majority of alcohol-related calls for service were for traumatic injuries, sexual assaults and rapes, poisonings or drug ingestions, and altered levels of consciousness. Conclusion. Alcohol consumption was a comorbid factor in illness and injury that necessitated prehospital emergency medical care in one Midwestern college town. Further research is needed to determine whether these results can be generalized beyond this one geographic location or if causality can be determined between alcohol consumption and injuries or illnesses that lead to emergency medical services calls.

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.

Meehan TJ; Bryant SM; Aks SE. Drugs of abuse: The highs and lows of altered mental states in the emergency department. Emergency Medicine Clinics of North America 28(3): 663-+, 2010. (57 refs.)

The diagnosis and management of poisoned patients presenting with alterations in mental status can be challenging, as patients are often unable (or unwilling) to provide an adequate history. Several toxidromes exist. Recognition hinges upon vital signs and the physical examination. Understanding these "toxic syndromes" may guide early therapy and management, providing insight into the patient's underlying medical problem. Despite toxidrome recognition guiding antidotal therapy, the fundamental aspect of managing these patients involves meticulous supportive care. The authors begin with a discussion of various toxidromes and then delve into the drugs responsible for each syndrome They conclude with a discussion on drug-facilitated sexual assault ("date rape"), which is both an underrecognized problem in the emergency department (ED) and representative of the drug-related problems faced in a modern ED.

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.

Murphy DA; Shetty V; Zigler C; Researchell J; Yamashita DD. Willingness of facial injury patients to change causal substance using behaviors. Substance Abuse 31(1): 35-42, 2010. (21 refs.)

Many injuries due to interpersonal violence among patients presenting to urban trauma centers for treatment are preventable, with alcohol and illicit drug use presenting as common antecedent risk factors. However, many patients with such problems do not seek treatment. Substance use patients were surveyed to determine how many recognized they had a problem and whether they had previously received treatment for substance use problems. Almost 60% of the patients treated for a facial injury screened for problem alcohol use, and slightly more than 25% screened for problem drug use. Only approximately one third of patients indicated any movement towards dealing with these problems and of these, only 20% had actually sought treatment. Employment had an effect on treatment seeking, with fewer employed patients seeking help. Utilizing the critical window of opportunity for emergency department (ED) personnel to make referrals may have an impact on treatment seeking for problem level substance use.

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.

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.

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.

Rossi J; Swan MC; Isaacs ED. The violent or agitated patient. Emergency Medicine Clinics of North America 28(1): 235-+, 2010. (57 refs.)

Violent and agitated patients are high risk because they may pose a physical threat to the staff, may harm themselves, and may have dangerous comorbidities and illness that are causing the violence. The emergency physician must quickly control these behaviors, and thoroughly identify and treat their etiology, while simultaneously protecting the patients' rights and reducing the risks of injury to themselves, other patients, and medical staff. This article highlights potentially high-risk situations and describes corresponding mitigation tactics.

Sandberg Y; Rood PPM; Russcher H; Zwaans JJM; Weigel JD; van Daele PLA. Falsely elevated lactate in severe ethylene glycol intoxication. Netherlands Journal of Medicine 68(7-8): 320-323, 2010. (14 refs.)

A 29-year-old male presented at the emergency department of our hospital in a confused state. He had a history of psychoses and substance abuse. Physical examination revealed hyperventilation and abdominal tenderness. Blood gas analysis in the emergency department using an ABL 725 Radiometer analyser showed a severe metabolic acidosis with massive lactate elevation. Lactate acidosis due to mesenteric ischaemia was suspected. However, toxicology screening demonstrated ethylene glycol intoxication. Treatment with ethanol infusion and acute haemodialysis was started. Repeated laboratory measurements using a clinical chemistry analyser showed minimal plasma lactate elevation. Falsely elevated lactate measurement is a little known phenomenon that can occur in ethylene glycol intoxication and can cause serious delay in diagnosis. Therefore, elevated lactate concentrations measured on intensive care unit and emergency department blood gas analysers should be confirmed by a clinical chemistry analyser in the main laboratory in case of suspected ethylene glycol intoxication.

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'.

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.

Stewart SH; Borg KT; Miller PM. Prevalence of problem drinking and characteristics of a single-question screen. Journal of Emergency Medicine 39(3): 291-295, 2010. (19 refs.)

Hazardous drinking and alcohol use disorders (i.e, abuse and dependence) are common in Emergency Departments (EDs). This study examined 1) the prevalence of these conditions among ED patients and 2) characteristics of a single screening question (having consumed at least five drinks for males or four for females during a single day). Data from the National Epidemiology Survey on Alcohol and Related Conditions were analyzed. Logistic regression for clustered data was used to estimate the relative risk for past-year ED use associated with hazardous drinking, abuse, and dependence. Contingency tables were analyzed to estimate the sensitivity and specificity of the single-question screen for detecting these conditions. Hazardous drinking was not associated with ED utilization. Alcohol abuse was associated with a relative risk of 1.3 (95% confidence interval [CI] 1.1-1.5) and alcohol dependence with a relative risk of 1.9 (95% CI 1.6-2.2). For current drinkers, the single question screen was 0.96, 0.85, and 0.90 sensitive for hazardous drinking, alcohol abuse, and alcohol dependence, respectively. Individuals with a positive screen in the past year were considered at least hazardous drinkers, and specificity was 0.80, 0.64, and 0.65 for hazardous drinking, abuse, and dependence, respectively. Specificity was modestly increased in women. Most problem drinkers were hazardous drinkers, but only severe alcohol use disorders were particularly prevalent in the ED. The single heavy-drinking-day item appears sensitive for problem drinking. Positive tests must be followed by additional assessment to differentiate hazardous drinking from alcohol use disorders.

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.

Turner J; Keller A; Bauerle J. The longitudinal pattern of alcohol-related injury in a college population: Emergency department data compared to self-reported data. American Journal of Drug and Alcohol Abuse 36(4): 194-198, 2010. (10 refs.)

Background: Self-report survey is the most common method of obtaining information from college students on substance use and its consequences. However, the validity and reliability of self-report data, especially in relationship to harmful substance use, is frequently called into question. Objectives: To establish the convergent validity of self-reported alcohol-related injury data and data from a university-affiliated hospital Emergency Department (ED) across a seven year period. (2) To examine the trend lines for relative risk of alcohol-related injury. Methods: Two existing data sets at a major public university are compared: records of 1,253 ED admissions for alcohol-related reasons and 13,518 survey responses. Convergent validity is evaluated with the Pearson correlation coefficients of the two data sets for 2001/2002 through 2007/2008. Longitudinal trends for each data set are evaluated by change in relative risk. Results: Over the seven years, 51% of ED visits for alcohol-related reasons were due to injury, and 14% of survey respondents who drank alcohol reported alcohol-related injury. Both decreased significantly over the years: from 62% to 45% for ED reports and from 24% to 9% for self reports. ED visits for alcohol-related injury and self-reported alcohol-related injury are highly correlated: r = .67, 45% shared variance. Conclusions: The comparison establishes convergent validity for the self-report data and decreased rates of alcohol-related injury. Scientific Significance: These findings support the validity in college populations of self-report data about negative consequences associated with drinking alcohol.

Vaca F; Winn D; Anderson C; Kim D; Arcila M. Feasibility of emergency eepartment bilingual computerized alcohol screening, brief intervention, and referral to treatment. Substance Abuse 31(4): 264-269, 2010. (15 refs.)

The purpose of this study was to assess the feasibility of utilizing a computerized alcohol screening and intervention (CASI) kiosk in an emergency department (ED). An interactive English and Spanish audiographical computer program, developed for used on a mobile computer cart, was administered to 5103 patients. Patients who screened at risk (19%) also received a fully computer-guided brief negotiated interview (BNI) and a printed personal alcohol reduction plan. A higher percentage of younger patients, and males (31% versus 16% females), screened at risk or dependent. Patient surveys indicated CASI was easy to use and over 75% did not prefer a medical professional over the computer. The ED-based bilingual computerized alcohol screening, brief intervention, and referral to treatment required little time to administer, was acceptable to patients, identified at-risk and dependent drinkers, and was able to provide personalized feedback and brief intervention.

Walton MA; Chermack ST; Shope JT; Bingham CR; Zimmerman MA; Blow FC; Cunningham RM. Effects of a brief intervention for reducing violence and alcohol misuse among adolescents: A randomized controlled trial. Journal of the American Medical Association 304(5): 527-535, 2010. (39 refs.)

Context: Emergency department (ED) visits present an opportunity to deliver brief interventions to reduce violence and alcohol misuse among urban adolescents at risk of future injury. Objective To determine the efficacy of brief interventions addressing violence and alcohol use among adolescents presenting to an urban ED. Design, Setting, and Participants: Between September 2006 and September 2009, 3338 patients aged 14 to 18 years presenting to a level I ED in Flint, Michigan, between 12 PM and 11 PM 7 days a week completed a computerized survey (43.5% male; 55.9% African American). Adolescents reporting past-year alcohol use and aggression were enrolled in a randomized controlled trial (SafERteens). Intervention: All patients underwent a computerized baseline assessment and were randomized to a control group that received a brochure (n = 235) or a 35-minute brief intervention delivered by either a computer (n = 237) or therapist (n = 254) in the ED, with follow-up assessments at 3 and 6 months. Combining motivational interviewing with skills training, the brief intervention for violence and alcohol included review of goals, tailored feedback, decisional balance exercise, role plays, and referrals. Main Outcome Measures: Self-report measures included peer aggression and violence, violence consequences, alcohol use, binge drinking, and alcohol consequences. Results: About 25% (n = 829) of screened patients had positive results for both alcohol and violence; 726 were randomized. Compared with controls, participants in the therapist intervention showed self-reported reductions in the occurrence of peer aggression (therapist, -34.3%; control, -16.4%; relative risk [RR], 0.74; 95% confidence interval [CI], 0.61-0.90), experience of peer violence (therapist, -10.4%; control, +4.7%; RR, 0.70; 95% CI, 0.52-0.95), and violence consequences (therapist, -30.4%; control, -13.0%; RR, 0.76; 95% CI, 0.64-0.90) at 3 months. At 6 months, participants in the therapist intervention showed self-reported reductions in alcohol consequences (therapist, -32.2%; control, -17.7%; odds ratio, 0.56; 95% CI, 0.34-0.91) compared with controls; participants in the computer intervention also showed self-reported reductions in alcohol consequences (computer, -29.1%; control, -17.7%; odds ratio, 0.57; 95% CI, 0.34-0.95). Conclusion: Among adolescents identified in the ED with self-reported alcohol use and aggression, a brief intervention resulted in a decrease in the prevalence of self-reported aggression and alcohol consequences.

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.

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.