Risk management or racial Bias? The disparate use of restraints in the Emergency Department of an Urban Safety-Net Hospital.

OBJECTIVES: Limited data exist on racial-ethnic differences in the application of restraints for patients visitng the emergency department (ED). This study examines whether there is an association between race and patient ED visit type with the application of four-point mechanical restraints in a high acuity safety-net urban academic hospital. METHODS: The study retrospectively reviewed 198,610 visits to the ED at Boston Medical Center made by patients between 18 and 89 years old between May 1, 2014 and May 1, 2019. ED visit type was categorized based on primary billing code for the visit as either medical or behavioral; behavioral visits were further categorized into 5 groups based on corresponding primary psychiatric billing code category. The relationships between race/ethnicity and four-point mechanical restraints were analyzed using binary logistic regression models in SPSS. RESULTS: 1.4% of unique visits involved the use of four-point mechanical restraints. Patients with a behavioral visit were significantly over 16 times more likely to be restrained than those with a medical visit. Black patients were significantly more likely to be restrained than white patients for behavioral visits but less likely for medical visits. Black and Hispanic patients were also significantly more likely to be restrained for a behavioral visit regardless of psychiatric diagnosis. Asian patients were less likely to be restrained regardless of ED visit type. CONCLUSIONS: Significant racial differences in restraints for White patients with medical visits and Black and Hispanic patients with behavioral visits prompts further investigation on the role of clinician bias when managing acute patients.

The Urge to Fight: Persistent Escalation by Alcohol and Role of NMDA Receptors in Mice.

Alcohol drinking, in some individuals, culminates in pathologically aggressive and violent behaviors. Alcohol can escalate the urge to fight, despite causing disruptions in fighting performance. When orally administered under several dosing conditions the current study examined in a mouse model if repeated alcohol escalates the motivation to fight, the execution of fighting performance, or both. Specifically, seven daily administrations of alcohol (0, 1.8, or 2.2 g/kg) determined if changes in the motivation to initiate aggressive acts occur with, or without, shifts in the severity of fighting behavior. Responding under the control of a fixed interval (FI) schedule for aggression reinforcements across the initial daily sessions indicated the development of tolerance to alcohol's sedative effect. By day 7, alcohol augmented FI response rates for aggression rewards. While alcohol escalated the motivation to fight, fighting performance remained suppressed across the entire 7 days. Augmented FI responding for aggression rewards in response to a low dose of alcohol (1.0 g/kg) proved to be persistent, as we observed sensitized rates of responding for more than a month after alcohol pretreatment. In addition, this sensitization of motivated aggression did not occur with a general enhancement of motor activity. Antagonism of NMDA or AMPA receptors with ketamine, dizocilpine, or NBQX during later challenges with alcohol were largely serenic without having any notable impact on the expression of alcohol-escalated rates of FI responding. The current dissociation of appetitive and performance measures indicates that discrete neural mechanisms controlling aggressive arousal can be distinctly sensitized by alcohol.