Linda C. Degutis

A brief intervention reduces hazardous and harmful drinking in emergency department patients.

STUDY OBJECTIVE Brief interventions have been shown to reduce alcohol use and improve outcomes in hazardous and harmful drinkers, but evidence to support their use in emergency department (ED) patients is limited. The use of research assessments in studies of brief interventions may contribute to uncertainty about their effectiveness. Therefore we seek to determine (1) if an emergency practitioner-performed Brief Negotiation Interview or a Brief Negotiation Interview with a booster reduces alcohol consumption compared with standard care; and (2) the impact of research assessments on drinking outcomes using a standard care-no-assessment group. METHODS We randomized 889 adult ED patients with hazardous and harmful drinking. A total of 740 received an emergency practitioner-performed Brief Negotiation Interview (n=297), a Brief Negotiation Interview with a 1-month follow-up telephone booster (Brief Negotiation Interview with booster) (n=295), or standard care (n=148). We also included a standard care with no assessments (n=149) group to examine the effect of assessments on drinking outcomes. Primary outcomes analyzed with mixed-models procedures included past 7-day alcohol consumption and 28-day binge episodes at 6 and 12 months, collected by interactive voice response. Secondary outcomes included negative health behaviors and consequences collected by telephone surveys. RESULTS The reduction in mean number of drinks in the past 7 days from baseline to 6 and 12 months was significantly greater in the Brief Negotiation Interview with booster (from 20.4 [95% confidence interval {CI} 18.8 to 22.0] to 11.6 [95% CI 9.7 to 13.5] to 13.0 [95% CI 10.5 to 15.5]) and Brief Negotiation Interview (from 19.8 [95% CI 18.3 to 21.4] to 12.7 [95% CI 10.8 to 14.6] to 14.3 [95% CI 11.9 to 16.8]) than in standard care (from 20.9 [95% CI 18.7 to 23.2] to 14.2 [95% CI 11.2 to 17.1] to 17.6 [95% CI 14.1 to 21.2]). The reduction in 28-day binge episodes was also greater in the Brief Negotiation Interview with booster (from 7.5 [95% CI 6.8 to 8.2] to 4.4 [95% CI 3.6 to 5.2] to 4.7 [95% CI 3.9 to 5.6]) and Brief Negotiation Interview (from 7.2 [95% CI 6.5 to 7.9] to 4.8 [95% CI 4.0 to 5.6] to 5.1 [95% CI 4.2 to 5.9]) than in standard care (from 7.2 [95% CI 6.2 to 8.2] to 5.7 [95% CI 4.5 to 6.9] to 5.8 [95% CI 4.6 to 7.0]). The Brief Negotiation Interview with booster offered no significant benefit over the Brief Negotiation Interview alone. There were no differences in drinking outcomes between the standard care and standard care-no assessment groups. The reductions in rates of driving after drinking more than 3 drinks from baseline to 12 months were greater in the Brief Negotiation Interview (38% to 29%) and Brief Negotiation Interview with booster (39% to 31%) groups than in the standard care group (43% to 42%). CONCLUSION Emergency practitioner-performed brief interventions can reduce alcohol consumption and episodes of driving after drinking in hazardous and harmful drinkers. These results support the use of brief interventions in ED settings.

Quality of life and facial trauma: psychological and body image effects.

This study evaluated the social and psychologic impact of facial trauma on previously healthy individuals. Inclusion criteria for the study included 18- to 45-year-old individuals who had a facial laceration of 3 cm or greater and/or a fractured facial bone requiring operative intervention within 6 months to 2 years prior to participation in the study. Retrospective analysis of patients at Yale New Haven Hospital Emergency Department was done between May 1997 and December 1998. When compared with a control population, the study group showed a statistically significant lower satisfaction with life, more negative perception of body image, higher incidence of posttraumatic stress disorder, higher incidence of alcoholism, and an increase in depression. Also, among the study group there was a significantly higher incidence of posttrauma unemployment, marital problems, binge drinking, jail, and lower attractiveness scores. In conclusion, in this preliminary study, it appears that the result of facial scarring/trauma includes a significantly decreased satisfaction with life, an altered perception of body image, a higher incidence of posttraumatic stress disorder, a higher incidence of alcoholism, and increased posttrauma jail, unemployment, binge drinking, and marital problems. Thus, it appears that there is significant negative social and functional impact related to facial trauma and scarring.

Prospective ultrasound evaluation of venous thrombosis in high-risk trauma patients.

UNLABELLED To determine the incidence of venous thrombosis (VT), high-risk trauma patients were evaluated prospectively biweekly with Doppler ultrasound (US). Fifty-seven patients during an 8-month period met high-risk criteria for VT including age > 45 years, > 2 days bed rest, previous history of thromboembolism, spine fracture, coma, spinal cord injury, pelvic fracture, lower extremity injury, or femoral vein catheter. Doppler ultrasound showed 16 VTs in 12 patients. Venous thrombosis occurred despite prophylaxis (heparin or compression devices) in 9 of 12 patients. Iliac VT was noted in four patients, two of whom had no lower extremity VT. Upper extremity VT occurred in two patients who had received central venous catheters. CONCLUSIONS (1) US surveillance may be valuable in high-risk trauma patients because VT is a common finding (21%), despite prophylactic measures. (2) Examination of the upper extremity and pelvic venous system appears to be important, since 33% (4 of 12) of our patients with VT developed thrombi isolated to these regions. These would not have been identified during routine lower extremity duplex studies.

Nonoperative management of adult blunt splenic trauma. Criteria for successful outcome.

Nonoperative management of blunt splenic trauma in adults is controversial despite numerous reports advocating this mode of therapy. Blunt splenic trauma is frequently managed without operation at our institution and, to define criteria that may predict a successful outcome, a retrospective review (1980 to 1988) of all adult splenic injuries was undertaken. Splenic injuries were documented by scintillation studies, CAT scanning, or at laparotomy. Sixty of 252 (24%) splenic injuries were initially treated without operation, which included bed rest, ICU monitoring, frequent physical exams, nasogastric tube, serial hematocrits, and follow-up splenic imaging. Five patients (5 of 60) failed nonoperative management and required interval laparotomy. Reasons for failure included blood loss greater than four units, enlarging splenic defect, or increasing peritoneal signs. Parameters predicting a successful outcome were localized trauma to the left flank or abdomen, hemodynamic stability, transfusion requirements less than four units, rapid return of GI function, age less than 60 years, and early resolution of splenic defects on imaging studies. No morbidity or deaths resulted from delayed operative intervention. In carefully selected adult patients, blunt splenic trauma may be successfully managed without operation.

Lessons from the past

The National Center for Health Statistics (NCHS) recently announced that poisoning had passed motor vehicle (MV) crashes as the leading cause of injury death in the USA in 2008.1 The NCHS also noted that nearly 90% of poisoning deaths were due to drugs, which have driven the overall poisoning mortality increase since at least 1980. Much of the increase in drug poisoning mortality was due to prescription drugs, especially opioid painkillers. Similar trends related to prescription opioids have been noted in other developed countries.2 3 Preliminary mortality data from 2009 suggest an additional large decline in MV crash deaths,4 5 while emergency department data suggest a continued increase in prescription drug overdoses in 2009.6 It is likely that drug poisoning alone now causes more deaths than MV crashes in the USA. These reported and anticipated changes represent a major milestone in injury prevention. A hundred years ago, falls were the leading mechanism of injury death in the USA.7 Beginning around 1910, MV …

Integrating Project ASSERT: A Screening, Intervention, and Referral to Treatment Program for Unhealthy Alcohol and Drug Use Into an Urban Emergency Department

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

Skiing and Snowboarding Head Injuries in 2 Areas of the United States

Abstract Objective.—To explore the use of helmets in skiers and snowboarders injured at ski runs and terrain parks in Colorado and the northeast United States and to examine differences in head injury severity in terrain parks as compared to ski runs. Methods.—This was a retrospective cohort study. We reviewed emergency department medical records of injured skiers at 9 medical facilities in Colorado, New York, and Vermont to examine the frequency of helmet use, type of terrain on which injuries occurred, and effect of injury event type and helmet use on change in mental status. Injuries that occurred from July 2002 to July 2004 were included. Eligible patients were skiers and snowboarders who sustained a head injury as defined by International Classification of Diseases-9 codes for acute head injuries. Data elements included event location, mechanism of injury, helmet use, loss of consciousness, neurologic findings, Glasgow Coma Scale score, and initial outcome. Data were entered into SPSS for analysis. Results.—Of 1013 patients, 52.6% were skiing, 46.7% were snowboarding, and the remainder engaged in other activities such as sledding or using a sit ski. Most (78.7%) were using a ski run, whereas 19.1% were at a terrain park when their injuries occurred, and 37.1% were wearing helmets. Most injuries (74.1%) occurred when the victim hit his/her head on the snow; 10.0% and 13.1% occurred in collisions with other skiers and fixed objects, respectively. There were significantly fewer instances of loss of consciousness in fall events in the Colorado group (χ2: 4.127; P < .05), a significantly lower incidence of loss of consciousness in helmet users who struck a fixed object (χ2: 5.800; P < .05), and a significantly higher incidence of skiers colliding with fixed objects in the Northeast (χ2: 14.05; P < .005). There were significantly more documented head injuries in terrain parks, even when controlling for helmet use (χ2: 5.800; P < .05). Conclusion.—There is an increased risk of head injury, regardless of helmet use, at terrain parks as compared to ski runs, and helmets were notably protective in collisions with fixed objects. Regional differences in injury events were noted in that there were more fall-related head injuries and a higher incidence of collisions with fixed objects in the Northeast compared to Colorado.

Developing and Implementing a Multispecialty Graduate Medical Education Curriculum on Screening, Brief Intervention, and Referral to Treatment (SBIRT)

The authors sought to evaluate the feasibility and acceptability of initiating a Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol and other drug use curriculum across multiple residency programs. SBIRT project faculty in the internal medicine (traditional, primary care internal medicine, medicine/pediatrics), psychiatry, obstetrics and gynecology, emergency medicine, and pediatrics programs were trained in performing and teaching SBIRT. The SBIRT project faculty trained the residents in their respective disciplines, accommodating discipline-specific implementation issues and developed a SBIRT training Web site. Post-training, residents were observed performing SBIRT with a standardized patient. Measurements included number of residents trained, performance of SBIRT in clinical practice, and training satisfaction. One hundred and ninety-nine residents were trained in SBIRT: 98 internal medicine, 35 psychiatry, 18 obstetrics and gynecology, 21 emergency medicine, and 27 pediatrics residents. To date, 338 self-reported SBIRT clinical encounters have occurred. Of the 196 satisfaction surveys completed, the mean satisfaction score for the training was 1.60 (1 = very satisfied to 5 = very dissatisfied). Standardized patient sessions with SBIRT project faculty supervision were the most positive aspect of the training and length of training was a noted weakness. Implementation of a graduate medical education SBIRT curriculum in a multispecialty format is feasible and acceptable. Future efforts focusing on evaluation of resident SBIRT performance and sustainability of SBIRT are needed.

Prevention of injury and violence in the USA

In the first three decades of life, more individuals in the USA die from injuries and violence than from any other cause. Millions more people survive and are left with physical, emotional, and financial problems. Injuries and violence are not accidents; they are preventable. Prevention has a strong scientific foundation, yet efforts are not fully implemented or integrated into clinical and community settings. In this Series paper, we review the burden of injuries and violence in the USA, note effective interventions, and discuss methods to bring interventions into practice. Alliances between the public health community and medical care organisations, health-care providers, states, and communities can reduce injuries and violence. We encourage partnerships between medical and public health communities to consistently frame injuries and violence as preventable, identify evidence-based interventions, provide scientific information to decision makers, and strengthen the capacity of an integrated health system to prevent injuries and violence.

Epidemiology of firearm mortality and injury estimates : State of Connecticut, 1988-1993

STUDY OBJECTIVES To retrospectively determine the 6-year cumulative incidence rate of firearm mortality and estimate nonfatal firearm injuries in Connecticut. METHODS Retrospective analysis of data originating from the Connecticut State Medical Examiners Office and records from the Trauma Registry of one urban hospital. RESULTS From January 1988 through December 1993, 1,625 Connecticut residents died from firearm-related injuries. The cumulative incidence rate was 49.4 deaths per 100,000 population during the 6-year study period. Rates peaked among 20- to 24-year-olds at 18.1 deaths per 100,000. Males outnumbered females more than eightfold. The ratio of nonfatal firearm injuries to firearm deaths was 7:1 for those shot by another, self-inflicted injuries were fatal in half of all cases. CONCLUSION Analysis of firearm mortality data indicated that males in younger age categories were disproportionately affected. These rates combined with nonfatal injury projections demonstrate that firearms represent a significant public health threat to the population of Connecticut, reaching epidemic proportions among specific subpopulations. These results are consistent with those obtained from national studies.