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CORK Bibliography: Emergency Medicine

65 citations. October 2007 to present

Prepared: September 2008

Apodaca TR; Miller WR; Schermer CR; Amrhein PC. A pilot study of bibliotherapy to reduce alcohol problems among patients in a hospital trauma center. Journal of Addictions Nursing 18(4): 167-173, 2007. (37 refs.)

Because alcohol use plays a major role in many injuries that require hospital care, there is increasing interest in developing interventions to address alcohol problems among emergency department and trauma center patients. The aim of the current study was to extend past research on brief interventions by investigating the use of a self-help manual to treat problem drinkers in a hospital trauma center. Forty injured patients who were either intoxicated at the time of injury or screened positive for harmful drinking were randomly assigned to receive either a brief assessment and a self-help booklet with no more than 5 minutes clinician contact (bibliotherapy) or brief assessment only. Follow-up data obtained five months after hospital discharge indicated that patients in both conditions made significant reductions in drinking and associated negative consequences. There was a trend toward further treatment-seeking among those in the bibliotherapy condition (40% versus 13%). Results suggest that the provision of self-help materials to treat problem drinkers identified in a hospital trauma setting may not bring about behavior change beyond that observed following hospitalization and an assessment of drinking. Caution in the interpretation of results is warranted due to the small sample size.

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

Baird J; Longabaugh R; Lee CS; Nirenberg TD; Woolard R; Mello MJ et al. Treatment completion in a brief motivational intervention in the emergency department: The effect of multiple interventions and therapists' behavior. Alcoholism: Clinical and Experimental Research 31(10, Supplement S): 71S-75S, 2007. (18 refs.)

Background: The aim of this study was to identify therapist behaviors during a brief motivational intervention (BMI) given to injured emergency department patients that predicted participant return for a second BMI session and 12-month alcohol-related outcomes. Methods: This was a secondary data analysis of a randomized controlled trial (n = 539) previously demonstrating that random assignment to a BMI and booster session resulted in a significant reduction of 12-month postintervention alcohol-related injuries and negative consequences relative to standard care. Results: Participants who actually received 2 BMI sessions had significantly less alcohol-related negative consequences than those who received only 1 BMI session. Therapists who reported a higher focus on emotional support and low focus on participant drinking behaviors during the initial BMI session were more likely to have assigned participants return for the second BMI session. Conclusions: The results of these secondary analyses show that compliance with a 2-session therapeutic intervention (BIB) predicted fewer negative alcohol-related consequences, and that therapists' supportive emotional emphasis during the first BMI session was important in predicting participants returning for the second MI session.

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

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

Bazargan-Hejazi S; Gaines T; Duan NH; Cherpitel CJ. Correlates of injury among ED visits: Effects of alcohol, risk perception, impulsivity, and sensation seeking behaviors. American Journal of Drug and Alcohol Abuse 33(1): 101-108, 2007. (15 refs.)

This cross-sectional study used a random sample of 412 Emergency Department (ED) patients to test the following hypothesizes: 1) injury would be positively associated with problem drinking and recent drinking; 2) impulsivity and sensation seeking would be positively associated with injury, while risk perception would be negatively associated with injury. Results show recent drinking is associated with 2-fold increase in the odds of injury [OR and 95%; CI=2.34 (1.07-5.10)] while problem drinking and personality factors were unrelated to injury. Other significant predictors were gender and age. Findings suggest a need for alcohol screening for patients who check themselves into the ED due to injury.

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

Boudreaux ED; Baumann BM; Camargo CA; O'Hea E; Ziedonis DM. Changes in smoking associated with an acute health event: Theoretical and practical implications. Annals of Behavioral Medicine 33(2): 189-199, 2007. (47 refs.)

Background. Experiencing a serious adverse behavior-related consequence may motivate behavior change. Purpose: To examine how a sentinel health event is associated with changes in smoking. Methods: We used a prospective cohort design. Adult emergency department (ED) patients provided demographic data, a smoking history, ratings of quit intentions, and endorsement of self-identified smoking-related health problems. A chart review collected data on acuity, ED disposition, and medical diagnoses. Smoking was reassessed I month postvisit. Hierarchical regression analyses were conducted to predict (a) intention to quit, (b) any quit attempt of 24 hr or more, and (3) 7-day abstinence. Results: Of 717 smokers enrolled, 189 (26%) intended to quit within the next month. Of the 253 participants reached I month postvisit, 126 (50%) reported they had attempted to quit, with 44 (19%) reporting 7-day abstinence. After controlling for other predictors, several event-related variables, such as having a smoking-related ED visit and being admitted to the hospital, were strong predictors of outcomes. Conclusion: Compared to community-based estimates, many more smokers in our sample attempted to quit and achieved 7-day abstinence. This was especially true among smokers who attributed their ED visit to a smoking-related health problem and who were admitted to the hospital. We discuss the implications for tobacco intervention design in medical settings.

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

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

Bratcher L; Clayton EW; Greeley C. Children in methamphetamine homes: A survey of physicians practicing in southeast Tennessee. Pediatric Emergency Care 23(10): 696-702, 2007. (5 refs.)

Objectives: Methamphetamine (meth) abuse in the rural South has increased greatly in the last decade. This addiction harms meth abusers and producers and endangers children who live with them. Appropriate medical evaluation and treatment of these exposed children are largely undefined. The objective of this research was to ascertain how emergency medical practitioners view this problem and their management approaches. Methods: A survey of medical practices was mailed to 87 physicians associated with emergency departments and child services in 12 southeastern Tennessee counties with high rates of meth lab seizures. This survey asked about physicians' examination of children in provided clinical scenarios who may have been exposed to meth, their assessment of the severity of the meth problem in their area, and the utility of a standardized protocol for management. Twenty-six practitioners responded. Results: In a clinical scenario developed to suggest high possibility of meth exposure, the average response regarding likelihood of meth exposure was 8 on a scale of 1 to 10. In a scenario suggesting ambiguous exposure, the physicians' mean response about likelihood of meth exposure was 4 on a scale of I to 10. In a third scenario presenting a confirmed meth exposure, physicians ordered the following tests: toxicology screening (96%), complete blood count (88%), oxygen saturation (76%), chest radiograph (72%), and carboxyhemoglobin concentration (52%). Ninety-two percent of respondents felt that medical knowledge of meth could be improved. Conclusions: Southeastern Tennessee emergency practitioners varied in their estimation of the likelihood of meth exposure to children in different scenarios. In addition, their clinical responses to cases of definite exposure were highly divergent. These practitioners also stated that standardized guidelines would aid in providing care for meth-exposed children.

Bray JW; Zarkin GA; Miller WR; Mitra D; Kivlahan DR; Martin DJ; Couper DJ; Cisler RA. Measuring economic outcomes of alcohol treatment using the economic form 90. Journal of Studies on Alcohol and Drugs 68(2): 248-255, 2007. (35 refs.)

Objective: This article assesses the ability of the economic outcome measures in the Economic Form 90 to detect differences across levels of alcohol dependence as measured by the Alcohol Dependence Scale. Method: We used baseline data from the Combining Medications and Behavioral Interventions (COMBINE) Study, a large, multisite clinical trial, to assess the extent to which the economic items on the Economic Form 90 instrument can detect differences across levels of alcohol dependence. Results: After adjusting for differences in demographic characteristics, the Economic Form 90 can detect significant differences across a range of dependence severity levels for the economic outcomes of inpatient medical care, emergency-department medical care, behavioral health care, being on parole or probation, and missed workdays, conditional or being employed. We did not detect significant differences across dependence severity for employment status, outpatient medical care, other criminal justice involvement, or motor vehicle accidents. Conclusions: The Economic Form 90 can identify differences in many economic outcomes associated with differing levels of alcohol dependence. This suggests that the Economic Form 90 may be useful in assessing changes in economic outcomes that result from changes in alcohol dependence.

Breton AR; Taira DA; Burns E; O'Leary J; Chung RS. Follow-up services after an emergency department visit for substance abuse. American Journal of Managed Care 13(9): 497-505, 2007. (39 refs.)

Objective: The recent introduction of substance abuse treatment measures to the Health Plan Employer and Data Information Set (HEDIS) highlights the importance of this area for managed care organizations (MCOs). Particularly challenging are members first diagnosed in an emergency department (ED). Study Design: Retrospective claims analysis. Methods: Claims were abstracted for all members who used an ED in 2004 for a diagnosis of substance abuse in a large commercial MCO. General linear models were used to estimate the association between receiving follow-up care within 14 and 60 days and sex, age, type of primary diagnosis, substance abused, and level of use. Results: Of the 1235 patients who visited an ED with a diagnosis of substance abuse, 13% received follow-up substance abuse services within 14 days of their ED visit. An additional 36% of patients had an outpatient service that did not code a substance abuse diagnosis within 2 weeks of an ED visit. The diagnosis breakdown of patients' primary diagnoses was 28% substance use, 13% mental health issues, and 59% noripsychiatric (medical) disorders. The multivariable regression analyses revealed having a nonpsychiatric (medical) primary diagnosis was the strongest predictor of not receiving follow-up care (relative risk = 0,51) at 14 days compared with patients who had a mental health diagnosis. Conclusions: Training ED staff and nonbehavioral health outpatient providers in treatment follow-up for substance abuse may improve the quality of care for patients. Encouraging providers to code for substance abuse when treatment or counseling is delivered would improve health plan HEDIS scores. Interventions may be needed for frequent ED users with substance abuse.

Budnitz DS; Pollock DA; Weidenbach KN; Mendelsohn AB; Schroeder TJ; Annest J. National surveillance of emergency department visits for outpatient adverse drug events. Journal of the American Medical Association 296(15): 1858-1866, 2006. (48 refs.)

Context: Adverse drug events are common and often preventable causes of medical injuries. However, timely, nationally representative information on outpatient adverse drug events is limited. Objective To describe the frequency and characteristics of adverse drug events that lead to emergency department visits in the United States. Design, Setting, and Participants: Active surveillance from January 1, 2004, through December 31, 2005, through the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project. Main Outcome Measures: National estimates of the numbers, population rates, and severity (measured by hospitalization) of individuals with adverse drug events treated in emergency departments. Results: Over the 2-year study period, 21,298 adverse drug event cases were reported, producing weighted annual estimates of 701,547 individuals (95% confidence interval [CI], 509 642-893 452) or 2.4 individuals per 1000 population (95% CI, 1.7-3.0) treated in emergency departments. Of these cases, 3487 individuals required hospitalization (annual estimate, 117 318 [16.7%]; 95% CI, 13.1%-20.3%). Adverse drug events accounted for 2.5% (95% CI, 2.0%-3.1%) of estimated emergency department visits for all unintentional injuries and 6.7% (95% CI, 4.7%-8.7%) of those leading to hospitalization and accounted for 0.6% of estimated emergency department visits for all causes. Individuals aged 65 years or older were more likely than younger individuals to sustain adverse drug events (annual estimate, 4.9 vs 2.0 per 1000; rate ratio [RR], 2.4; 95% CI, 1.8-3.0) and more likely to require hospitalization (annual estimate, 1.6 vs 0.23 per 1000; RR, 6.8; 95% CI, 4.3-9.2). Drugs for which regular outpatient monitoring is used to prevent acute toxicity accounted for 41.5% of estimated hospitalizations overall (1381 cases; 95% CI, 30.9%-52.1%) and 54.4% of estimated hospitalizations among individuals aged 65 years or older (829 cases; 95% CI, 45.0%-63.7%). Conclusions: Adverse drug events among outpatients that lead to emergency department visits are an important cause of morbidity in the United States, particularly among individuals aged 65 years or older. Ongoing, population-based surveillance can help monitor these events and target prevention strategies.

Bunting PJ; Fulde GW; Forster SL. Comparison of crystalline methamphetamine ("ice") users and other patients with toxicology-related problems presenting to a hospital emergency department. Medical Journal of Australia 187(10): 564-566, 2007. (9 refs.)

Objective: To compare demographic and clinical characteristics of methamphetamine users and patients with other toxicology-related problems requiring medical intervention in a hospital emergency department (ED). Design and setting: Prospective observational study of toxicology-related presentations to the ED of St Vincent's Hospital (SVH), Sydney, an inner-city tertiary hospital, between 1 October and 31 December 2006. Main outcome measures: Differences between methamphetamine-related and other toxicology-related presentations to the ED in relation to behaviour, mode of arrival, accompaniment, need for scheduling, location of drug use, intravenous drug use history, psychiatric history and demographic characteristics. Results: During the study period there were 10 305 patient presentations to SVH ED; 449 (4%) were toxicology-related presentations, of which 100 (1% of total) were methamphetamine-related. Methamphetamine users were significantly more agitated, violent and aggressive than patients with other toxicology-related presentations and significantly less alert, communicative and cooperative (P < 0.001); 24% of methamphetamine users (24/100) arrived with police accompaniment versus 9% of other toxicology patients (33/349) (P < 0.00 1). Methamphetamine users were more likely to Have a history of intravenous drug use and mental health problems (P < 0.001); 39% of methamphetamine presentations (39/100) required scheduling under the Mental Health Act 1990 (NSW) compared with 19% of other toxicology-related presentations (67/349) (P < 0.001); 43% of methamphetamine-related presentations (43/100) involved drug use on the street compared with 24% of other toxicology-related presentations (83/349) (P < 0.001). Two-thirds of all methamphetamine users were male, and the most common age group for both male and fernale users was 26-30 years. The mean age and sex distribution of patients with other toxicology-related presentations were not significantly different. Among methamphetamine users, 27% of women (9/33) were in the 21-25-year age group compared with 10% (7/67) of men (P < 0.001). Conclusion: There were significant differences between methamphetamine-related and other toxicology-related presentations to SVH ED. Methamphetamine users were more aggressive, violent and dangerous, and thus more likely to pose a risk to health personnel and others. Methamphetamine appeared to be used consistently, rather than as an episodic "party drug".

Cherpitel CJ; Ye Y; Bond J; Borges G; Macdonald S; Stockwell T et al. Validity of self-reported drinking before injury compared with a physiological measure: Cross-national analysis of emergency-department data from 16 countries. Journal of Studies on Alcohol and Drugs 68(2): 296-302, 2007. (31 refs.)

Objective: Self-reports of alcohol consumption among patients visiting an emergency department (ED) have been used extensively in the investigation of the relationship between drinking and injury. Little is known, however, about the associations between validity of self-reports with patient and injury characteristics and whether these relationships vary across regions or countries. Both of these issues are explored in this article. Method: In the construct of a multilevel logistical model, validity of self-reports was estimated as the probability of a positive self-report given a positive blood alcohol concentration (BAC). The setting included 44 EDs across 28 studies in 16 countries. Participants included 10,741 injury patients from the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the World Health Organization Collaborative Study of Alcohol and Injuries. Data were analyzed on self-reported drinking within 6 hours before injury compared with BAC results obtained from breath-analyzer readings in all but two studies, which used urine screens. Covariates included demographic, drinking, and injury characteristics and aggregate-level contextual variables. Results: At the individual level, a higher BAC measurement was associated with a higher probability of reporting drinking, as was heavy drinking and sustaining injuries in traffic accidents or violence-related events. At the study level, neither aggregate BAC nor other sociocultural variables affected the validity of self-reported drinking. Conclusions: This study provides further evidence of the validity of self-reported drinking measures in crossnational ED studies based on the objective criterion of BAC estimates.

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

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

Csipke E; Touquet R; Patel T; Franklin J; Brown A; Holloway P et al. Use of blood alcohol concentration in resuscitation room patients. Emergency Medicine Journal 24(8): 535-538, 2007. (26 refs.)

Objective: To clarify the use of blood alcohol concentration (BAC) in the emergency department resuscitation room, by comparing it with a subsequent alcohol questionnaire and by surveying patients' attitudes to BAC testing. Design: Observational study. Participants: 273 resuscitation room patients at St Mary's Hospital, Paddington between August 2005 and February 2006. Main outcome measures: BAC comparison to questionnaire results, and attitudes to BAC testing. Results: The level of agreement between positive screening by questionnaire and a BAC of >80 mg/100 ml was low (kappa=0.29, 95% confidence interval 0.12 to 0.46) because each test measures different aspects of drinking. Patients accepted the use of BAC tests in detecting alcohol use, though a small minority reported concerns over confidentiality. Conclusion: Use of BAC testing complements later questionnaire screening to identify alcohol misuse in patients initially brought to the emergency department resuscitation room, providing results are fed back to the patient. Potential ethical, judicial and insurance concerns should not prevent the use of BAC when judged to be in the patient's best interest.

Cunningham R; Walton MA; Tripathi SP; Weber JE; Maio RF; Booth BM. Past-year violence typologies among patients with cocaine-related chest pain. American Journal of Drug and Alcohol Abuse 33(4): 571-582, 2007. (23 refs.)

This study examines a consecutive cohort of patients (n 219) presenting to an urban Emergency Department (ED) for cocaine-related chest pain (June 2002 to February 2005). Patients were interviewed regarding violence, substance use, and psychosocial factors. Significant markers of violence were increases in: past- year medical service use, binge drinking, marijuana use, cocaine diagnosis, but not cocaine use days. Rates and correlates of violence differed by relationship type (intimate partner, nonpartner) and role context (victimization, perpetration). Understanding these correlates has public health implications, both for preventing future violence and its associated ED service utilization, and for future interventions in cocaine users presenting to the ED.

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

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

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

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

Daeppen JB; Gaume J; Bady P; Yersin B; Calmes JM; Givel JC; Gmel G. Brief alcohol intervention and alcohol assessment do not influence alcohol use in injured patients treated in the emergency department: A randomized controlled clinical trial. Addiction 102(8): 1224-1233, 2007. (39 refs.)

Aims: To evaluate the effectiveness of brief alcohol intervention (BAI) in reducing alcohol use among hazardous drinkers treated in the emergency department (ED) after an injury; in addition it tests whether assessment of alcohol use without BAI is sufficient to reduce hazardous drinking. Design: Randomized controlled clinical trial with 12-month follow-up conducted between January 2003 and June 2005. Setting: Urban academic emergency department (ED) of the Lausanne University Hospital, Lausanne, Switzerland. Participants A total of 5136 consecutive patients attending ED after an injury completed a seven-item general and a three-item alcohol screen and 1472 (28.7%) were positive for hazardous drinking according to the National Institute on Alcohol Abuse and Addiction definition; of these 987 (67.1%) were randomized into a BAI group (n = 310) or a control group with screening and assessment (n = 342) or a control group with screening only (n = 335) and then a total of 770 patients (78.0%) completed the 12-month follow-up procedures. Intervention: A single 10-15-minute session of standardized BAI conducted by a trained research assistant. Measurements: Percentage of participants who have changed to low-risk drinking at follow-up. Findings: Data obtained at 12 months indicated that similar proportions were low-risk drinkers in BAI versus control groups with and without assessment (35.6%, 34.0%, 37.0%, respectively, P = 0.71). Data also indicated similar reductions in drinking frequency, quantity, binge drinking frequency and Alcohol Use Disorders Identification Test (AUDIT) scores across groups. All groups reported similar numbers of days hospitalized and numbers of medical consults in the last 12 months. A model including age groups, gender, AUDIT and injury severity scores indicated that BAI had no influence on the main alcohol use outcome. Conclusions: This study provides the evidence that a 10-15-minute BAI does not decrease alcohol use and health resource utilization in hazardous drinkers treated in the ED, and demonstrates that commonly found decreases in hazardous alcohol use in control groups cannot be attributed to the baseline alcohol assessment. [Note: A correction/addendum is published in Addiction 102(12): 1224-1233.]

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

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

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

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

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

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

Dunford J; Castillo EM; Chan TC et al. Impact of the San Diego Serial Inebriate Program on Use of Emergency Medical Resources. Annals of Emergency Medicine 47(4): 328-336, 2006. (22 refs.)

Study objective: We determine the impact of a treatment strategy called the San Diego Serial Inebriate Program on the use of emergency medical services (EMS) and emergency department (ED) and inpatient services by individuals repeatedly arrested for public intoxication. Methods: This was a retrospective review of health care utilization records (EMS, ED, and inpatient) of 529 individuals from 2000 to 2003. Judges offered individuals a 6-month outpatient treatment program in lieu of custody (Serial Inebriate Program). Demographics and health care utilization are reported overall and by treatment acceptance. Results: From 2000 to 2003, 308 of 529 (58%) individuals were transported by EMS 2,335 times; 409 of 529 (77%) individuals amassed 3,318 ED visits, and 217 of 529 (41%) individuals required 652 admissions, resulting in 3,361 inpatient days. Health care charges totaled $17.7 million (EMS, $1.3 million; ED, $2.5 million; and inpatient, $13.9 million). Treatment was offered to 268 individuals, and 156 (58%) accepted. Use of EMS, ED, and inpatient services declined by 50% for clients who chose treatment, resulting in an estimated decrease in total monthly average charges of $5,662 (EMS), $12,006 (ED), and $55,684 (inpatient). There was no change in use of services for individuals who refused treatment. There was a significant increasing trend in acceptance among individuals with longer jail sentences (<0.001). Treatment acceptance was 20% among those with sentences of 0 to 30 days and reached 63% for those with sentences longer than 150 days. Operational costs and alternate care at clinics and nonparticipating hospitals were not analyzed. Conclusion: This community-supported treatment strategy reduced the use of EMS, ED, and inpatient resources by individuals repeatedly intoxicated in public.

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

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

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

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

Gee P; Richardson S; Woltersdorf W; Moore G. Toxic effects of BZP-based herbal party pills in humans: A prospective study in Christchurch, New Zealand. New Zealand Medical Journal 118: 1227, 2005

AIM: This study describes patterns of human toxicity related to the use of 1-benzylpiperazine (BZP)-based 'herbal party pills'. METHODS: From 1 April 2005 to 1 September 2005 all presentations associated with party pill use were captured on a prospective data collection form. RESULTS: There were 61 patients who presented on 80 occasions to the Emergency Department of Christchurch Hospital, New Zealand. Patients with adverse effects took an average of 4.5 tablets/capsules. Patients with mild to moderate toxicity experienced symptoms such as insomnia, anxiety, nausea, vomiting, palpitations, dystonia, and urinary retention. Some adverse reactions persisted up to 24 hours after ingestion. Fifteen toxic seizures were recorded. Two patients suffered life-threatening toxicity with status epilepticus and severe respiratory and metabolic acidosis. CONCLUSIONS: Herbal party pills have been sold without regulation since 2000, and are now widely used by young New Zealanders. The principal ingredient of these pills is 1-benzylpiperazine (BZP). They appear to have a narrow safety margin when used recreationally by some humans, possibly because of intrinsic pharmacodynamic properties, self-dosing variability, or genetic polymorphism. Those with seizure disorders or coronary disease should avoid BZP as should those taking prescription sympathomimetics or anticholinergics. Coingestion with MDMA or amphetamine should also be cautioned against. The results of this study indicate that BZP can cause unpredictable and serious toxicity in some individuals. Furthermore, the results of this study should be carefully considered in any discussion on the legal status of piperazine-based party pills.

Gmel G; Givel JC; Yersin B; Daeppen JB. Injury and repeated injury: What is the link with acute consumption, binge drinking and chronic heavy alcohol use? Swiss Medical Weekly 137(45-46): 642-648, 2007. (43 refs.)

Objectivcs: First, to test whether current injury is more closely related to acute intake than to usual consumption patterns, and second, to test whether repeated injury is more closely related to general consumption patterns than to acute intake. Methods: Screening of alcohol consumption of 7,872 patients enrolling between january 1, 2003 and June 30, 2004 in an emergency department (ED) in Lausanne, Switzerland. General consumption patterns were measured as usual volume (in drinks per week) and binge drinking (5+ drinks for men; 4+ drinks for women) at least once monthly. Acute intake was measured through number of drinks in the 24-hour period prior to attending the ED. Separate logistic regression models of current injury and repeated injury on alcohol consumption patterns were estimated. Results: Acute intake and binge drinking dominated the association with current injury, while general consumption patterns were predictive of repeated alcohol-related injury. Conclusions: Acute intake is associated with current injury in a dose-response relationship and with binge drinking. Because acute intake can be found among moderate volume drinkers as well as among chronic heavy drinkers, for current injury usual volume adds little predictive value over the effects of acute intake. Repeated injuries occur more often among chronic heavy drinkers, and thus general consumption patterns are more closely associated with injury "recidivism" than with acute intake. A screening question assessing prior injury may be a useful tool in the ED for distinguishing between chronic heavy drinkers and usually moderate drinkers with heavy drinking episodes, and thus prove helpful when creating preventive efforts tailored to different types of drinker.

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

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

Green R. The management of severe toxic alcohol ingestions at a tertiary care center after the introduction of fomepizole. American Journal of Emergency Medicine 25(7): 799-803, 2007. (21 refs.)

Introduction: Ethylene glycol and methanol ingestions are relatively uncommon but potentially lethal poisonings. Recent trials have demonstrated that fomepizole effectively blocks alcohol dehydrogenase (ADH) in toxic alcohol overdoes, and may eliminate the need for emergent hemodialysis and intensive care unit admission. However, controversy remains in the role of fomepizole in clinical practice. The purpose of this study was to describe the presentation, management and clinical course of toxic alcohol ingestions at a tertiary care referral center after the introduction of fomepizole to hospital formulary. Methods: Data was collected on all patents treated for toxic alcohol ingestions for a 1-year period in a tertiary care referral center. Patients who received fomepizole or ethanol infusions, or who underwent hemodialysis were indentified by ED, pharmacy, hemodialysis and ICU databases. The patients' medical records were reviewed, and data was recorded on a predetermined computerized data collection form. Results: Overall, twenty (20) toxic ingestions (14 methanol; 6 ethylene glycol) were identified over the one year period. Fomepizole was used for ADH blockade in 12/20 cases; ETOH infusions in 15/20 cases (combined ETOH and fomepizole use in 7/20). The majority of toxic alcohol exposures were admitted to an intensive care unit (19/20) and received emergent hemodialysis (19/20). All patients were discharged from hospital alive. Conclusions: Patients with methanol and ethylene glycol ingestions who presented to our centers had significant toxicity and received both HD and ICU admission. Further research is required to determine if the method of ADH blockade affects the need for hemodialysis or ICU admission in toxic alcohol ingestions.

Greene J. Serial inebriate programs: What to do about homeless alcoholics in the emergency department. (editorial). Annals of Emergency Medicine 49(6): 791-793, 2007. (1 refs.)

Every inner-city emergency department (ED) has a core group of alcoholics who have either failed or refused treatment many times over, consuming massive amounts of health care resources. Many approaches to control these costs and treat the recidivists have failed. An innovative effort in San Diego, CA, is gaining national attention. James Dunford, an emergency physician at University of California, San Diego Medical Center, decided to find out just how much local EDs were spending on serial inebriates while their true, long term needs for treatment and housing were going ignored. The tally showed a total of $1.5 million spent on just 15 randomly selected chronic drunks for their care in 2 local EDs and transport by emergency services during an 18-month period in 1997-98. They totaled 417 ED visits among them. This information provided to San Diego city officials sparked an alternative. The six month program known as the Serial Inebriate Program (SIP), starts out with the basics: essential skills for living -- not rehabilitation, but habilitation. The first 30 days are directed to modeling social behaviors, such as hygiene, riding the bus, feeding themselves, taking medications. We're just trying to get the guy to shave and bathe in the first month. In the second or third, we'll get them employment. Clients may need to go through the program multiple times to be successful, not an indication that treatment doesn't work, just that it takes a lot of time and effort to make such huge behavior changes. The San Diego program has housing for 15 people at a time, and pays for 10 beds in private residential treatment facilities. Clients are provided with communal living in 4 apartments and come to treatment 3 times a week on an outpatient basis.

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

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

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

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

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

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

Mahabee-Gittens EM; Huang B; Slap GB; Gordon JS. An emergency department intervention to increase parent-child tobacco communication: A pilot study. Journal of Child & Adolescent Substance Abuse 17(2): 71-83, 2007. (34 refs.)

We conducted a randomized trial of parents and their 9- to 16-year-old children to pilot test an emergency department (ED)-based intervention designed to increase parent-child tobacco communication. Intervention group (IG) parents received verbal/written instructions on how to relay anti-tobacco messages to their children; control group (CG) parents received no specific instructions. Of the 540 subjects, 268 (49.6%) were randomized to the IG; both groups were similar at baseline. At one-month follow-up, IG children, were more likely to report that they would definitely not smoke in the next 6 months (96.3% and 88.4%, p =0.01), that there were an increased number of child-initiated tobacco conversations (F(1,386) = 5.7, p = 0.02), times parents talked to them about: refusing cigarettes (F(1,380) = 7.6, p = 0.006), and reasons not to smoke (F(1,377) = 6.0, p = 0.015). Our pilot study has shown increases in parent-child tobacco communication after an ED-based intervention, suggesting that the ED may be an appropriate setting to encourage parent-child tobacco communication.

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

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

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

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

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

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

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

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

Monti PM; Barnett NP; Colby SM; Gwaltney CJ; Spirito A; Rohsenow DJ et al. Motivational interviewing versus feedback only in emergency care for young adult problem drinking. Addiction 102(8): 1234-1243, 2007. (36 refs.)

Aim: To establish the efficacy of a brief motivational intervention compared to feedback only when delivered in an emergency department for reducing alcohol use and problems among young adults. Design: Two-group randomized controlled trial with follow-up assessments at 6 and 12 months. Setting: Level I Trauma Center. Participants A total of 198 18-24-year-old patients who were either alcohol positive upon hospital admission or met screening criteria for alcohol problems. Intervention Participants were assigned randomly to receive a one-session motivational intervention (MI) that included personalized feedback, or the personalized feedback report only (FO). All participants received additional telephone contact 1 month and 3 months after baseline. Measurements: Demographic information, alcohol use, alcohol problems and treatment seeking. Findings: Six months after the intervention MI participants drank on fewer days, had fewer heavy drinking days and drank fewer drinks per week in the past month than did FO patients. These effects were maintained at 12 months. Clinical significance evaluation indicated that twice as many MI participants as FO participants reliably reduced their volume of alcohol consumption from baseline to 12 months. Reductions in alcohol-related injuries and moving violations, and increases in alcohol treatment-seeking were observed across both conditions at both follow-ups with no differences between conditions. Conclusions: This study provides new data supporting the potential of the motivational intervention tested to reduce alcohol consumption among high-risk youth.

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

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

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

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

Nietert PJ; French MT; Kirchner JE; Booth BM. Utilization and cost of mental health, substance abuse, and medical services among at-risk drinkers. Medical Care Research and Review 64(4): 431-448, 2007. (49 refs.)

The objective of this research was to examine whether users of mental health or substance abuse (MH/SA) services incurred greater costs for non-MH/SA services than nonusers of MH/SA services. Two years of health care utilization data were collected on 443 at-risk drinkers from six southern U.S. states. We then examined predictors of using MH/SA services and costs associated with non-MH/SA services. The results showed that use of MH/SA services was associated with female gender, military service, health insurance, and not being employed full-time. Unadjusted analyses indicated that non-MH/SA service costs were significantly higher among MH/SA service users than nonusers. However, this association did not endure in multivariable models. In fact, emergency department costs were significantly lower among MH/SA users. It is commonly assumed that users of MH/SA services are also heavy users of other medical services. Through multivariable models, this study found that overall costs of nonMH/SA services were similar between users and nonusers of MH/SA services.

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

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

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2005: National Estimates of Drug-Related Emergency Department Visits. DAWN Series D-29. Rockville MD: Substance Abuse and Mental Health Services Administration, 2007. (24 refs.)

SAMHSA's Drug Abuse Warning Network (DAWN) provides national data on emergency department visits involving illicit drugs, alcohol, and nonmedical use of pharmaceuticals. In 2005, general non-Federal hospitals delivered 108 million emergency department visits. An estimated 1,449,154 of these emergency visits were associated with drug misuse or abuse. Cocaine was involved in 448,481 visits; marijuana in 242,200 visits; heroin in 164,572 visits, and stimulants (including amphetamines and methamphetamines) were involved in 138,950 emergency department visits. Alcohol-related visits accounted for 34% of all drug misuse or drug abuse emergency department visits. Alcohol was most frequently combined with cocaine alone (86,482 visits), marijuana alone (33,643 visits), cocaine and marijuana (22,377 visits), and heroin alone (12,797 visits). Opiates/opioid analgesics accounted for 33% of the nonmedical visits and included: Hydrocodone/combinations (51,225 visits), Oxycodone/combinations (42,810 visits), methadone (41,216 visits), and fentanyl/combinations (9,160 visits). Anti-anxiety agents (sedatives and hypnotics) accounted for 34% of the nonmedical visits and included benzodiazepines (172,388 visits). There are 28 figures and tables

Public Domain

O'Toole TP; Pollini R; Gray P; Jones T; Bigelow G; Ford DE. Factors identifying high-frequency and low-frequency health service utilization among substance-using adults. Journal of Substance Abuse Treatment 33(1): 51-59, 2007. (20 refs.)

Understanding why substance-using patients seek care at emergency departments (EDs) and who utilizes such service at high rates is important in tailoring and targeting interventions. We conducted a retrospective/prospective cohort study of 326 medically ill substance-using adults to identify factors associated with 12-month high-frequency utilization of ambulatory care, ED, and inpatient medical care. The majority were actively using heroin (74.6%), cocaine (62.4%), and alcohol (54.4%); 94.8% had a chronic medical condition; and 53.8% reported a chronic mental health condition. High-frequency use of ED (>= 3 visits) was independently associated with being female (adjusted odds ratio [AOR] = 1.88; 95% confidence interval [95% Cl] = 1.12, 3.17), being African American (AOR = 2.36; 95% Cl 1.30, 4.29), being homeless (AOR = 2.07; 95% Cl = 1,08, 3.96), a history of > 1 substance abuse treatment episode (AOR = 4.10-1 95% Cl 3.28, 10.87), and >= I ambulatory care visit (AOR = 8.94; 95% Cl = 3.28, 24.41). However, the combination of having certain chronic conditions (seizure disorder, hepatitis B, and hepatitis Q and accessing ambulatory care was protective against high-frequency use of ED. In contrast, high-frequency use of ambulatory care (. 3 visits) was independently associated with having insurance (Medicare/Medicaid: ACR = 2.39; 95% Cl = 1.31, 4.69), having HIV/AIDS (AOR = 3.15; 95% Cl 1.70, 5.85), and receiving substance abuse treatment during the study period (AOR = 3.58; 95% Cl = 1.61, 7.98) Efforts to redirect medical care to more subacute settings will likely require both capacity building and addressing a client's underlying needs, including homelessness, access to substance abuse treatment, and chronic disease management.

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

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

Pasic J; Russo JE; Ries RK; Roy-Byrne PP. Methamphetamine users in the psychiatric emergency services: A case-control study. American Journal of Drug and Alcohol Abuse 33(5): 675-686, 2007. (17 refs.)

The purpose of this study is to examine the sociodemographic, clinical, and service use characteristics of patients with positive methamphetamine (MA) urine toxicology and compare with non-MA users seen in an urban Psychiatric Emergency Services (PES). One hundred twenty patient charts were extracted for demographics, mode of arrival, clinical information, medication treatment of MA-intoxication, and disposition. Compared with non-MA patients, MA patients were significantly younger, male, referred by police, with cardiac symptoms, psychosis, dysphoria, past substance use, and were less likely to have a diagnosis of schizophrenia, a past psychiatric history/hospitalization, and a history of suicide attempts. Subsequent hospitalization rates did not differ. MA patients treated with medications more readily accepted the referral to chemical dependency treatment. This study shows that hypertension and tachycardia upon arrival to the PES, symptoms of dysphoria and psychosis, past substance use and not having the diagnosis of schizophrenia are all related to methamphetamine use.

Patton R; Strang J; Birtles C; Crawford MJ. Alcohol: A missed opportunity. A survey of all accident and emergency departments in England. Emergency Medicine Journal 24(8): 529-531, 2007. (24 refs.)

Aim: To determine the extent to which the recommendations of the alcohol harm reduction strategy for England and the Choosing Health white paper for the provision of screening and brief interventions for hazardous and harmful drinkers have been adopted by accident and emergency departments. Method: Telephone/postal survey of all 191 Type 1 departments in England. The survey was part of a larger study investigating the impact of the changes in the licensing act (2004) on alcohol-related attendances. Results: 4 departments use formal screening tools and 24 ask general questions about consumption (98.9% response rate). Blood alcohol levels were measured as required by 100 departments. No departments routinely measure blood alcohol, and 84 departments never assess blood alcohol levels. Alcohol-related attendances were formally recorded by 131 departments. Access to an alcohol health worker or a clinical nurse specialist was reported by 32 departments. Discussion: Although departments may be willing to address hazardous alcohol consumption, the low numbers of departments utilising formal screening tools suggests that patients who may benefit from help or advice remain undetected.

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

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

Pollini RA; Strathdee SA. Indicators of methamphetamine use and abuse in San Diego County, California: 2001-2005. Journal of Psychoactive Drugs Suppl. 4: 319-325, 2007. (13 refs.)

San Diego County, California, is a major distribution center for methamphetamine entering the U.S. from Mexico. All available indicators suggest that the use and abuse of methamphetamine increased between 2001 and 2005. Drug treatment admissions for primary methamphetamine use accounted for 49% of all drug treatment admissions in 2005, up from 37% in 2001, with trends showing smaller proportions of female and Hispanic users and a larger proportion of methamphetamine smokers (vs. inhalation or injection). Increases in prevalence of methamphetamine use were documented among arrestees as well; by 2005, 51% of female and 21% of juvenile arrestees tested positive for methamphetamine. The proportion of emergency department visits involving illicit drugs in which methamphetamine was reported increased from 32% in 2004 to 40% in 2005, although this change was not statistically significant, and methamphetamine-related deaths increased 48% between 2001 and 2005. Data from non-federal drug seizures in San Diego County documented an increase from 21% of all drug items analyzed in 2001 to 32% in 2005. In summary, methamphetamine remains the drug of utmost concern in San Diego. The availability of multiple data sources is imperative for constructing valid characterizations of trends in methamphetamine use and abuse and its affect on health.

Puljula J; Savola O; Tuomivaara V; Pribula J; Hillbom M. Weekday distribution of head traumas in patients admitted to the emergency department of a city hospital: Effects of age, gender and drinking pattern. Alcohol and Alcoholism 42(5): 474-479, 2007. (36 refs.)

Aims: To define the alcohol-related risk for head traumas and to compare the weekly and monthly variations in alcohol consumption, and the occurrence of head traumas in a population with heavy episodic drinking as the prevailing drinking pattern. Methods: All consecutive admissions due to head trauma into a Finnish city hospital during 1 year (1999) were recorded. 832 consecutive patients with data on alcohol consumption were covered. We compared the number of final diagnoses of head traumas per day and month to the anticipated frequency in the absence of any weekly or monthly variation. Official statistics on alcohol consumption in Finland are presented as reference. Results: Alcohol-related head traumas were most common in young adults and people of working age. The occurrence of head traumas in sober subjects showed no temporal variations. By contrast, alcohol-related cases peaked on weekends and in the most popular vacation month (July). The alcohol-related risk from Friday to Sunday was 27.3% in women and 20.3% in men. The additional risk related to alcohol consumption in July was 16.1% in women and 5.3% in men. Conclusions: We found an excess of head traumas during weekends and the primary vacation month, and this excess was associated with heavy episodic drinking. Active measures are needed to prevent head traumas caused by this type of behaviour.

Rassool GH; Villar-Luis M; Braga VD. Co-morbidity: Psychiatric disorders and substance misuse in a psychiatric emergency unit in Brazil - An exploratory study. Journal of Addictions Nursing 18(3): 141-145, 2007. (30 refs.)

The aim of the study is to examine the prevalence rate of psychiatric disorders and substance misuse in patients admitted to the psychiatric emergency unit in Ribeirao Preto, Sao Paulo, Brazil. The data was obtained from SAME (Servico de Arquivo Medico e Estatistico) and the method used in this study is an examination of 500 patients admitted to the emergency psychiatric unit in the year 2000. The data was from the Service of Medical and Statistical Unit of the Hospital Clinic of Ribeirao Preto. The findings show that the prevalence rate of dual diagnosis for first time admissions and re-admissions was 32.6% and 33.8% respectively. The highest rate of admissions is observed in the 20 to 39 age range (55.3% of the total admissions) which is predominantly male. The majority of patients admitted were diagnosed with the coexistence of alcohol and psychiatric disorders (59%). About 42% had alcohol dependence syndrome and 30% of those admitted were suffering from abstinence or withdrawal syndrome as a result of alcohol misuse. Only 11% were diagnosed with schizophrenia. The study has implications for the adequate preparation of mental health nurses in working with dual diagnosis and for service provision.

Reis J. Bad luck or bad decisions: College students' perceptions of the reasons for and consequences of their alcohol overdose. Journal of Drug Education 17(9): 71-81, 2007. (32 refs.)

Reasons for and immediate consequences of an alcohol overdose were explored for 217 undergraduate students requiring a medical emergency transport because of excessive alcohol consumption. The sample was categorized into 26 students attributing their overdose solely to bad luck and 191 students citing bad decision making as an explanation. A discriminant analysis portrayed the bad luck students as more likely to change the type of alcohol consumed, worrying more about problems with friends, less likely to change how much they drink and less likely to feel that they learned something about themselves. Friends were not named as being involved, but lapses in knowing how to pace consumption were frequently cited. Design of preventive educational programs for underage drinkers with the aim of avoiding an overdose is discussed.

Richmond TS; Hollander JE; Ackerson TH; Robinson K; Gracias V; Shults J et al. Psychiatric disorders in patients presenting to the emergency department for minor injury. Nursing Research 56(4): 275-282, 2007. (49 refs.)

Background: Thirty-five percent of all Emergency Department (ED) visits are for physical injury. Objectives: To examine the proportion of patients presenting to an ED for physical injury with a history of or current Axis I/II psychiatric disorders and to compare patients with a positive psychiatric history, a negative psychiatric history, and a current psychiatric disorder. Methods: A total of 275 individuals were selected randomly from adults presenting to the ED with a documented anatomic injury but with normal physiology. Exclusion criteria were: injury in the previous 2 years or from medical illness or domestic violence; or reported treatment for major depression or psychoses. Psychiatric history and current disorders were diagnosed using the Structured Clinical Interview for the Diagnostic and Statistical Manual Disorders, 4th edition (DSM-IV), a structured psychiatric interview. Three groups (positive psychiatric history, negative psychiatric history, current psychiatric disorder) were compared using Chisquare and analysis of variance. Results: The sample was composed of men (51.6%) and women (48.4%), with 57.1% Black and 39.6% White. Out of this sample, 103 patients (44.7%) met DSM-IV criteria for a positive psychiatric history (n = 80) or a current psychiatric disorder (n = 43). A past history of depression (24%) exceeded the frequency of a history of other disorders (anxiety, 6%; alcohol use/abuse, 14%; drug use/abuse, 15%; adjustment, 23%; conduct disorders, 14%). Current mood disorders (47%) also exceeded other current diagnoses (anxiety, 9%; alcohol, 16%; drug, 7%; adjustment, 7%; personality disorders, 12%). Those with a current diagnosis were more likely to be unemployed (p <.001) at the time of injury. Conclusions: Psychiatric comorbid disorders or a positive psychiatric history was found frequently in individuals with minor injury. An unplanned contact with the healthcare system (specifically an ED) for treatment of physical injury offers an opportunity for nurses to identify patients with psychiatric morbidity and to refer patients for appropriate therapy.

Rodriguez-Martos A; Castellano Y; Salmeron JM; Domingo G. Simple advice for injured hazardous drinkers: An implementation study. Alcohol and Alcoholism 42(5): 430-435, 2007. (24 refs.)

Aim: To evaluate the implementation of a screening and intervention procedure for hazardous drinkers in the routine praxis of an emergency service, without increasing the ED (emergency department) staff. Methods: Four stages of the implementation process were undertaken: exploration and adoption, programme installation, and initial implementation. Two hospitals participated, with a coordinator, four trainers and all the emergency nursing staff. Eligible patients were males over age 15 presenting at the weekend with a traffic injury. Screening was performed with five questions (the three items of alcohol use disorders identification test (AUDIT-C) plus two questions about drinking within 6 h before the crash). Hazardous drinkers and drivers who had driven while intoxicated were offered simple advice. The programme implementation was evaluated by reviewing the patients forms and by interviews and surveys of the nursing staff. Results: The study lasted for 27 weeks. Knowledge and compliance with the programme were good. However, only 25% of the eligible patients were identified. Simple advice was accomplished by 94.7% of those in need of it. Although the majority of nurses felt at ease performing the intervention, 75% considered the programme as a work overload and only 21% reckoned that it was feasible for the emergency service. Conclusion: The emergency setting poses important barriers to the implementation of brief interventions.

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

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

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

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

Stewart SH. Alcoholics in acute medical settings have increased risk for other drug, mood, and personality disorders. International Journal of Psychiatry in Medicine 37(1): 59-67, 2007. (29 refs.)

Objective: Brief medical management and alcohol pharmacotherapy are effective treatments for alcoholic participants enrolled in randomized controlled trials, and this suggests that alcoholism treatment may be delivered successfully in medical settings. However, medical patients may differ from clinical trial participants in ways that suggest a need for more intensive alcoholism treatment. To explore this possibility, this study evaluated the prevalence of mental health disorders in the U.S. population stratified by alcoholism and recent hospitalization or emergency room use. Methods: Data from the National Epidemiological Survey on Alcohol and Related Conditions were analyzed. Subjects with information on alcohol use disorders, emergency room use, hospitalization, and several mental health diagnoses were included (n = 41,961). Methods appropriate for complex survey data were used to determine the relative risk for mental health diagnoses as a function of a current alcohol use disorder and receipt of acute medical care (hospitalization or emergency room visits) within the past year. Results: Results showed that, relative to alcoholic adults who did not have an emergency room visit or hospitalization, alcoholic adults with use of these services had an increased prevalence of personality disorders, depression, and other drug use disorders. Conclusion: Research is needed to evaluate if these and other differences, will lead to poorer treatment outcomes for this group relative to the more selected populations included in medical management efficacy trials.

Summers SA; Glynne PA. Acute poisoning on the medical admissions unit. (editorial). Clinical Medicine 7(3): 277-279, 2007. (19 refs.)

Alcohol intoxication, deliberate medicinal overdoses and ingestion of (illegal) substances are common reasons for admission to emergency departments in the UK, particularly in inner city hospitals. This review discusses problems related to the ingestion of selected toxins. In terms of alcohol, attention here is directed to ethylene glycol, methanol and isopropyl alcohol - each of which can produce fatal intoxication through the ingestion of relatively small doses. The most common medicinal agents involved in overdose are paracetamol and salicylate. As for illicit recreational drugs, the problems of securing an accurate history are noted, along with the limitations of drug testing. The most prominent recreational agents are 3,4-methylenedioxymethamphetamine (MDMA or ecstasy); gamma-hydroxybutyrate (GHB or liquid ecstasy); flunitrazepam (Rohypnol); and ketamine (Ketalar). Each is described, including its presentation and management.

Walton MA; Cunningham RM; Chermack ST; Maio R; Blow FC; Weber J. Correlates of violence history among injured patients in an urban emergency department: Gender, substance use, and depression. Journal of Addictive Diseases 26(3): 61-75, 2007. (81 refs.)

This study surveyed consecutive injured patients (n = 320) in an urban emergency department (ED) regarding past year violence, substance use, and depression. Victimization and aggression variables (none = N, partner only = P, non-partner only = NP, and generalized/both partner and non-partner = G) were compared on gender, depression, and substance use/consequences. Findings were similar for victimization and aggression variables. Depression was significantly related to violence for women but not for men; women in the P group reported the most depression. Substance variables were significantly related to violence by gender groups. Men in NP and G groups reported the most binge drinking; men in the G group reported the most consequences and drug use. Women in P and G groups reported the most binge drinking and consequences; women in the P group reported the most drug use. Screening urban ED patients for violence is warranted, with interventions addressing both partner and non-partner violence.

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

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

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

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

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

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

Wryobeck JM; Walton MA; Curran GM; Massey LS; Booth BM. Complexities of cocaine users presenting to the emergency department with chest pain: Interactions between depression symptoms, alcohol use, and race. Journal of Addiction Medicine 1(4): 213-221, 2007. (55 refs.)

Chest pain is the most frequent cocaine-related medical event for which patients seek treatment in inner-city emergency departments (EDs). Given that depression increases risk for poor substance use and cardiac outcomes, knowledge of correlates of depressive symptoms among these out-of-treatment cocaine users is crucial to developing interventions for these inner-city populations that frequently present to the ED. A total of 219 individuals presenting to an inner-city ED with chest pain and recent cocaine use were divided into 2 groups based on scoring positive (42%) for moderate-to-severe depression on the Patient Health Questionnaire (PHQ-9). The depression symptoms group reported a significantly greater number of standard drinks per drinking occasion (7.1 versus 4.6) and a greater number of heavy drinking days (9 versus 5). A significant 3-way interaction effect found males and non-white females reporting a greater number of heavy drinking days were more likely to be in the depression symptoms group, whereas white females with a greater number of heavy drinking days were more likely to be in the nondepression symptoms group. Depression is clearly a problem among not-in-treatment cocaine users presenting to an inner-city ED; heavy drinking in concert with cocaine use increases the risk for depression, with important interactions by race and gender.