Screening for harmful substance use in emergency departments: a systematic review.

BACKGROUND: Substance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use. METHODS: We included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results. RESULTS: Our search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82-85% and specificities 70-77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies' risk of bias were mostly high or uncertain. CONCLUSIONS: Six screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.

The effects of acute exercise on visuomotor adaptation, learning, and inter-limb transfer.

Pairing an acute bout of lower-limb cycling exercise with skilled motor practice enhances acquisition and learning. However, it is not known whether an acute bout of exercise enhances a specific form of motor learning, namely motor adaptation, and if subsequent inter-limb transfer of this adaptation is enhanced. Seventeen young healthy participants performed a bout of cycling exercise and rest, on separate days, prior to right-arm reaching movements to visual targets under 45° rotated feedback of arm position (acquisition), followed by an immediate test of inter-limb transfer with the untrained left arm. After a 24-h delay, participants returned for a no-exercise retention test using the right and left arm with the same rotated visual feedback as acquisition. Results demonstrated that exercise enhanced right-arm adaptation during the acquisition and retention phases, and transiently enhanced aspects of inter-limb transfer, irrespective of usual levels of physical activity. Specifically, exercise enhanced movement accuracy, decreased reaction and movement time during acquisition, and increased accuracy during retention. Exercise shortened reaction time during the inter-limb transfer test immediately after right-arm acquisition but did not influence left-arm performance assessed at retention. These results indicate that an acute bout of exercise before practice enhances right-arm visuomotor adaptation (acquisition) and learning, and decreases reaction time during untrained left arm performance. The current results may have implications for the prescription of exercise protocols to enhance motor adaptation for healthy individuals and in clinical populations.

Changes to white matter microstructure in transient ischemic attack: A longitudinal diffusion tensor imaging study.

Transient ischemic attack (TIA) is associated with localized ischemic changes, identifiable by diffusion-weighted imaging. Past research has not considered whether TIA is also associated with diffuse changes to white matter microstructure; further past work has not tracked changes longitudinally. Here we examine whole-brain changes in fractional anisotropy (FA) in individuals with TIA presenting with sensorimotor symptoms. Twenty individuals with a recent (within 30 days) TIA and 12 healthy older adults were recruited. Participants underwent 3.0 T diffusion MRI at baseline; scans were repeated for the TIA group 90 days post-TIA. Track-based spatial statistics (TBSS) was used to conduct a voxel-wise analysis of FA between groups. FA was significantly lower in the TIA group relative to healthy controls, primarily in anterior white matter tracts including: forceps minor, anterior thalamic radiations, cingulum, inferior fronto-occipital fasciculus, and corticospinal tract. TBSS results informed an ROI-based longitudinal examination of FA in the TIA group. There were no changes to TBSS-identified clusters, forceps minor, or the corticospinal tract over time. There was lower FA in the anterior thalamic radiations in the TIA-affected hemisphere at baseline, but no difference between hemispheres at 90 days. In summary, individuals with TIA presenting with sensorimotor symptoms have decreased FA in tracts that are also implicated in sensorimotor function, which outlast the clinical symptoms associated with TIA. This suggests a more profound type of brain damage associated with TIA than has been typically described in past work. Diffusion tensor imaging may have utility as a marker of TIA-associated changes to white matter pathways. Hum Brain Mapp 38:5795-5803, 2017. © 2017 Wiley Periodicals, Inc.