Gregory Luke Larkin

A preliminary naturalistic study of low-dose ketamine for depression and suicide ideation in the emergency department.

We examined the preliminary feasibility, tolerability and efficacy of single-dose, intravenous (i.v.) ketamine in depressed emergency department (ED) patients with suicide ideation (SI). Fourteen depressed ED patients with SI received a single i.v. bolus of ketamine (0.2 mg/kg) over 1-2 min. Patients were monitored for 4 h, then re-contacted daily for 10 d. Treatment response and time to remission were evaluated using the Montgomery-Asberg Depression Rating Scale (MADRS) and Kaplan-Meier survival analysis, respectively. Mean MADRS scores fell significantly from 40.4 (s.e.m.=1.8) at baseline to 11.5 (s.e.m.=2.2) at 240 min. Median time to MADRS score ≤10 was 80 min (interquartile range 0.67-24 h). SI scores (MADRS item 10) decreased significantly from 3.9 (s.e.m.=0.4) at baseline to 0.6 (s.e.m. =0.2) after 40 min post-administration; SI improvements were sustained over 10 d. These data provide preliminary, open-label support for the feasibility and efficacy of ketamine as a rapid-onset antidepressant in the ED.

The Role of Intimate Partner Violence, Race, and Ethnicity in Help-Seeking Behaviors

Objective . Women experiencing intimate partner violence (IPV) have multiple health and social service needs but many, especially Hispanic, women may not access these resources. This research sought to examine the relationship between IPV and health and social services utilization (help-seeking behaviors), with a focus on racial and ethnic disparities. Design . Case-control study from an urban US emergency department population in which cases (women with IPV) and controls (women without IPV) were frequency matched by age group and race/ethnicity. Logistic regression analyses were performed to examine the relationship between IPV and help-seeking behaviors and between help-seeking behaviors and race/ethnicity among abused women. In addition, a stratified analysis was conducted to examine the relationship between acculturation and help-seeking behaviors among Hispanic women. Results . The sample included 182 cases and 147 controls. Among the health services, alcohol program, emergency department, and hospital utilization were significantly increased among IPV victims compared to non-victims after taking demographic and substance use factors into account. Similarly, IPV victims were more likely to access social/case worker services and housing assistance compared to non-victims. Specific help-seeking behaviors were significantly associated with race and ethnicity among IPV victims, with non-Hispanic white and black women more likely to use housing assistance and emergency department services and black women more likely to use police assistance compared to Hispanic women. Among all Hispanic women, low acculturation was associated with decreased utilization of social services overall and with any healthcare utilization, particularly among abused women. Conclusions . Social service and healthcare workers should be alerted to and screen for IPV among all clients. The need for increased outreach and accessibility of services for abused women in Hispanic communities in the USA should be addressed, with cultural and language relevance a key component of these efforts.

Effectiveness of ignition interlock devices in reducing drunk driving recidivism

OBJECTIVE To determine if ignition interlock devices reduce driving while intoxicated (DWI) recidivism. SEARCH STRATEGIES Cochrane Collaboration search strategies were used. SELECTION CRITERIA Studies for selection examined the effectiveness of interlock programs in a defined population. Studies were required to have a clear description of the program and outcomes evaluated, to have a comparison group and to provide interpretable data. DATA COLLECTION AND ANALYSIS A total of 31 studies were found. Ten studies met the selection criteria. Three of these studies were eliminated from further analysis because they did not contain original data. A fourth study was eliminated due to methodologic weaknesses, leaving six studies for final review and analysis. Pooled analyses were not done because studies did not follow similar methods over comparable time periods. MAIN RESULTS Five of the six studies found interlocks were effective in reducing DWI recidivism while the interlock was installed in the car. In the five studies demonstrating a significant effect, participants in the interlock programs were 15%-69% less likely than controls to be re-arrested for DWI. The only reported randomized, controlled trial demonstrated a 65% reduction in re-arrests for DWI in the interlock group, compared with the control group. CONCLUSIONS Alcohol ignition interlock programs appear to be effective in reducing DWI recidivism during the time period when the interlock is installed in the car. Future studies should attempt to control for exposure (i.e., number of miles driven) and determine if certain sub-groups are most benefited by interlock programs.

Trends in US emergency department visits for suicide attempts, 1992-2001.

This article describes trends in suicide attempt visits to emergency departments in the United States (US). Data were obtained from the National Hospital Ambulatory Medical Care Survey using mental-health-related ICD-9-CM, E and V codes, and mental-health reasons for visit. From 1992 to 2001, mental-health-related visits increased 27.5% from 17.1 to 23.6 per 1000 (p < .001). Emergency Department (ED) visits for suicide attempt and self injury increased by 47%, from 0.8 to 1.5 visits per 1000 US population (p(trend) = .04). Suicide-attempt-related visits increased significantly among males over the decade and among females from 1992/1993 to 1998/1999. Suicide attempt visits increased in non-Hispanic whites, patients under 15 years or those between 50-69 years of age, and the privately insured. Hospitalization rates for suicide attempt-related ED visits declined from 49% to 32% between 1992 and 2001 (p = .04). Suicide attempt-related visits increased significantly in urban areas, but in rural areas suicide attempt visits stayed relatively constant, despite significant rural decreases in mental-health related visits overall. Ten-year regional increases in suicide attempt-related visits were significant for the West and Northeast only. US emergency departments have witnessed increasing rates of ED visits for suicide attempts during a decade of significant reciprocal decreases in postattempt hospitalization. Emergency departments are increasingly important sites for identifying, assessing and treating individuals with suicidal behavior.

Universal screening for intimate partner violence in the emergency department: Importance of patient and provider factors

STUDY OBJECTIVE Screening for intimate partner violence has been widely advocated in the health care setting, but efforts to assess effectiveness and ensure adequacy of universal screening are largely untested. We sought to identify barriers to screening of female emergency department patients for intimate partner violence during the first year of implementation of a screening protocol. METHODS A retrospective, structured medical chart review of 1,638 randomly identified visits included demographic factors of age, race, marital status, employment status, insurance status, arrival mode, mechanism of presenting complaint, severity of condition, presentation time, and nurse gender. The study was conducted an an inner-city Level I trauma center with 43,000 annual ED visits and universal procedures for screening for intimate partner violence in place since February 1994. The participants were a cohort of 1,509 female patients, 18 years of age or older, who were discharged from the ED between July 1994 and June 1995. The main outcome measure was the odds of being screened as a function of patient and provider variables. Statistical analyses involved univariate and multivariate logistic regression on screening rates (Yes/No) as derived from universal screening instrument variables. RESULTS Of 1,638 records reviewed, 483 patients (29.5%) were screened for intimate partner violence. Univariate analyses revealed that women presenting with nonpsychiatric, less acute complaints and those who presented during daylight hours were more likely to be screened than women who presented with psychiatric or more acute complaints, or during the night shift. Male and female nurse providers were equally likely to screen for intimate partner violence. Step-down multivariate analyses agreed with these findings. CONCLUSION In this random sample of female patients, screening rates varied by severity of the patients condition, type of presenting complaint, and presentation time.

Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic

To compare the efficacy of intramuscular ketorolac and meperidine in the emergency department (ED) treatment of renal colic, a prospective, controlled, randomized, double-blind trial was conducted in an academic ED with 76,000 annual visits. Participants were volunteer ED patients with a diagnosis of ureterolithiasis confirmed by intravenous pyelogram. Subjects were randomized 1:1 to receive a single intramuscular injection of either 60 mg ketorolac or 100 to 150 mg meperidine, based on weight. Of the 70 patients completing the trial, 33 received ketorolac and 37 received meperidine. Demographic characteristics and baseline pain scores of both groups were comparable (P = NS, Mann Whitney U). Ketorolac was significantly (P < .05) more effective than meperidine in reducing renal colic at 40, 60, and 90 minutes as measured on a 10-cm visual analogue scale. Similar proportions of patients in each group were given rescue analgesia and admitted. Of patients who were discharged home without rescue, those treated with ketorolac left the ED significantly earlier than those treated with meperidine (3.46 v 4.33 h, P < .05). These results show that intramuscular ketorolac as a single agent for renal colic is more effective than meperidine and promotes earlier discharge of renal colic patients from the ED.

Mental Health and Emergency Medicine: A Research Agenda

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.

Effect of an administrative intervention on rates of screening for domestic violence in an urban emergency department.

OBJECTIVES This study measured the effects of an administrative intervention on health care provider compliance with universal domestic violence screening protocols. METHODS We used a simple, interrupted-time-series design in a stratified random sample of female emergency department patients 18 years or older (n = 1638 preintervention, n = 1617 postintervention). The intervention was a 4-tiered hospital-approved disciplinary action, and the primary outcome was screening compliance. RESULTS Preintervention and postintervention screening rates were 29.5% and 72.8%, respectively. Before the intervention, screening was worse on the night shift (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.31, 0.68) and with psychiatric patients (OR = 0.34, 95% CI = 0.14, 0.85); after the intervention, no previous screening barriers remained significant. CONCLUSIONS An administrative intervention significantly enhanced compliance with universal domestic violence screening.

Fight or flight: the ethics of emergency physician disaster response

Most disaster plans depend on using emergency physicians, nurses, emergency department support staff, and out-of-hospital personnel to maintain the health care system’s front line during crises that involve personal risk to themselves or their families. Planners automatically assume that emergency health care workers will respond. However, we need to ask: Should they, and will they, work rather than flee? The answer involves basic moral and personal issues. This article identifies and examines the factors that influence health care workers’ decisions in these situations. After reviewing physicians’ response to past disasters and epidemics, we evaluate how much danger they actually faced. Next, we examine guidelines from medical professional organizations about physicians’ duty to provide care despite personal risks, although we acknowledge that individuals will interpret and apply professional expectations and norms according to their own situation and values. The article goes on to articulate moral arguments for a duty to treat during disasters and social crises, as well as moral reasons that may limit or override such a duty. How fear influences behavior is examined, as are the institutional and social measures that can be taken to control fear and to encourage health professionals to provide treatment in crisis situations. Finally, the article emphasizes the importance of effective risk communication in enabling health care professionals and the public to make informed and defensible decisions during disasters. We conclude that the decision to stay or leave will ultimately depend on individuals’ risk assessment and their value systems. Preparations for the next pandemic or disaster should include policies that encourage emergency physicians, who are inevitably among those at highest risk, to “stay and fight.”

Increased cortisol in women with intimate partner violence-related posttraumatic stress disorder

Abstract:  Intimate partner violence (IPV) is a chronic and recurrent traumatic stressor associated with PTSD; however, its biological correlates are not well understood. This study examined diurnal salivary cortisol and platelet catecholamines in women with lifetime IPV‐related PTSD and in women exposed to IPV who did not develop PTSD. Cortisol was elevated in women with lifetime PTSD compared to controls. No differences were found for platelet catecholamines.