Harmful alcohol use among injured adult patients presenting to a Ghanaian emergency department.

We performed a nested convenience sample survey of harmful alcohol use among injured patients aged 18 years and older treated in the Komfo Anokye Teaching Hospital (Kumasi, Ghana) emergency department (ED). Data from the Alcohol Use Disorder Identification Test, alcohol breath or saliva tests, patient demographics and injury characteristics were collected from an administered survey and medical chart review. A total of 403 subjects were surveyed, and 107 (27%; 95% CI 22 to 31) reported harmful alcohol use. High rates of harmful alcohol use were found among males (35%), acutely alcohol-positive subjects (55%), drivers (32%), pedestrians (35%) and assault victims (43%). A substantial proportion of injured patients reported harmful alcohol use. The data obtained support routine screening of injured patients presenting to Ghanaian EDs for harmful alcohol use.

Frequency of Alcohol Use Among Injured Adult Patients Presenting to a Ghanaian Emergency Department.

STUDY OBJECTIVE: Injuries are the cause of almost 6 million deaths annually worldwide, with 15% to 20% alcohol associated. The frequency of alcohol-associated injury varies among countries and is unknown in Ghana. We determined the frequency of positive alcohol test results among injured adults in a Ghanaian emergency department (ED). METHODS: This is a cross-sectional chart review of consecutive injured patients aged 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within 8 hours of injury. Patients were tested for presence of alcohol with a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death before admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals were calculated. RESULTS: Injured adult patients (2,488) presented to the ED from November 2014 to April 2015, with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95% confidence interval 32% to 38%) tested alcohol positive. Forty-two percent of men (320/756), 40% of subjects aged 25 to 44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assault victims (82/166), 40% of those seriously injured (124/311), and 53% of subjects who died in the ED (8/15) had positive results for presence of alcohol. CONCLUSION: The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary care hospital ED. These findings have implications for health policy-, ED- and legislative-based interventions, and acute care.

A survey of emergency physicians' fear of malpractice and its association with the decision to order computed tomography scans for children with minor head trauma.

OBJECTIVE: The objective of the study was to determine whether fear of malpractice is associated with emergency physicians' decision to order head computed tomography (CT) in 3 age-specific scenarios of pediatric minor head trauma. We hypothesized that physicians with higher fear of malpractice scores will be more likely to order head CT scans. METHODS: Board-eligible/board-certified members of the Michigan College of Emergency Physicians were sent a 2-part survey consisting of case scenarios and demographic questions. Effect of fear of malpractice on the decision to order a CT scan was evaluated using a cumulative logit model. RESULTS: Two hundred forty-six members (36.5%) completed the surveys. In scenario 1 (infant), being a male and working in a university setting were associated with reduced odds of ordering a CT scan (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.18-0.88; and OR, 0.35; 95% CI, 0.13-0.96, respectively). In scenario 2 (toddler), working for 15 years or more, at multiple hospitals, and for a private group were associated with reduced odds of ordering a CT scan (OR, 0.46; 95% CI, 0.26-0.79; OR, 0.36; 95% CI, 0.16-0.80; and OR, 0.51; 95% CI, 0.27-0.94, respectively). No demographic variables were significantly associated with ordering a CT scan in scenario 3 (teen). Overall, the fear of malpractice was not significantly associated with ordering a CT scan (OR, 1.28; 95% CI, 0.73-2.26; and OR, 1.70; 95% CI, 0.97-3.0). Only in scenario 2 was high fear significantly associated with increased odds of ordering a CT scan (OR, 2.09; 95% CI, 1.08-4.05). CONCLUSIONS: Members of Michigan College of Emergency Physicians with a higher fear of malpractice score tended to order more head CT scans in pediatric minor head trauma. However, this trend was shown to be statistically significant only in 1 case and not overall.

Characteristics of a mild head injury subgroup with extreme, persisting distress on the Rivermead Postconcussion Symptoms questionnaire.

UNLABELLED: Kirsch NL, de Leon MB, Maio RF, Millis SR, Tan-Schriner CU, Frederiksen S. Characteristics of a mild head injury subgroup with extreme, persisting distress on the Rivermead Postconcussion Symptoms Questionnaire. OBJECTIVE: To examine baseline variables and identify characteristics of participants with extremely high reports of symptoms (ie, outliers) 12 months after mild head injury (MHI). DESIGN: A prospective cohort study of MHI with and without loss of consciousness (LOC) and/or posttraumatic amnesia (PTA) recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months. SETTING: Level II community hospital ED. PARTICIPANTS: Participants (n=58) with MHI and LOC less than or equal to 30 minutes and/or PTA less than 24 hours and participants (n=173) with MHI but no PTA/LOC. INCLUSION CRITERIA: age greater than or equal to 18 years, less than or equal to 24 hours after injury, Glasgow Coma Scale score greater than or equal to 13, and discharge from the ED. Fourteen (6%) participants had extremely high scores on the Rivermead Postconcussion Symptoms Questionnaire (RPQ). MAIN OUTCOME MEASURES: RPQ and questions on health services use and litigation. RESULTS: Characterizing the outlier cases are prior head injury, preinjury disability, history of substance use, unemployment, and elevated somatic symptoms at the ED. At 12 months, outliers had higher use of health services and litigation. CONCLUSIONS: The existence of a subgroup with a distinctive pattern of baseline characteristics in combination with elevated somatic symptoms at the time of presentation to the ED suggests that further taxonomic distinctions may be warranted for the MHI population, each requiring appropriately targeted interventions for addressing symptomatic complaints.

Caregiver adherence to follow-up after an emergency department visit for common pediatric illnesses: Impact on future ED use.

BACKGROUND: Access to primary care is often a problem for children living in urban areas and the rate of emergency department (ED) use can be high. For acute childhood illnesses, primary care follow-up is often recommended to prevent subsequent ED visits. METHODS: We conducted an observational study of 455 children with common childhood illnesses, between 6 weeks and 8 years of age, presenting to 1 of 3 EDs, and discharged to the community. ED physicians recommended that the child visit their primary care physician within 1 to 4 days of discharge (ie, "short-term" follow-up). Caregivers were surveyed during the ED index visit and after discharge to assess primary care follow-up adherence. We collected data on child and caregiver characteristics, type and severity of illness at the ED index visit, and ED return visits in the 2-month period after the ED index visit. RESULTS: A total of 45.3% of caregivers adhered to short-term primary care follow-up. Short-term follow-up adherence was associated with greater ED use for the same illness over the subsequent 2 months (odds ratio = 2.97; 95% confidence interval, 1.31-6.72). Subsequent ED use was greatest for children with short-term primary care follow-up and: (1) prior ED use, (2) single caregivers, (3) mild severity illnesses at the ED index visit, or (4) younger children. ED use after the initial visit did not vary by type of illness or site. CONCLUSIONS: There was no evidence that primary care follow-up soon after an ED visit was associated with a lower rate of subsequent ED use for common pediatric illnesses.

One-year medical outcomes and emergency department recidivism after emergency department observation for cocaine-associated chest pain.

STUDY OBJECTIVE: Chest pain is the most common complaint among cocaine users who present to the emergency department (ED) seeking care, and many hospital resources are applied to stratify cocaine users in regard to future cardiac morbidity and mortality. Little is known about the longitudinal cardiac and noncardiac medical outcomes of cocaine users who have been stratified to an ED observation period after their ED visit. We examine 1-year cardiac outcomes in a low- to intermediate-risk sample of patients with cocaine-associated chest pain in an urban ED, as well as examine ED recidivism at 1 year for cardiac and noncardiac complaints. METHODS: Prospective consecutive cohort study of patients (18 to 60 years) who presented to an urban Level I ED with cocaine-associated chest pain and were risk stratified to low to intermediate cardiac risk. Exclusion criteria were ECG suggestive of acute myocardial infarction, increased serum cardiac markers, history of acute myocardial infarction or coronary artery bypass graft, hemodynamic instability, or unstable angina. Baseline interviews using validated measures of health functioning and substance use were conducted during chest pain observation unit stay and at 3, 6, and 12 months. ED utilization during the study year was abstracted from the medical chart. Zero-inflated Poisson regression analyses were conducted to predict recurrent ED visits. RESULTS: Two hundred nineteen participants (73%) were enrolled, 65% returned to the ED post-index visit, and 23% returned for chest pain; of these, 66% had a positive cocaine urine screening result. No patient had an acute myocardial infarction within the 1-year follow-up period. Patients with continued cocaine use were more likely to have a recurrent ED visit (P<.001), but these repeated visits were most often related to musculoskeletal pain (21%) and injury (30%), rather than potential cardiac complaints. CONCLUSION: Patients with cocaine-associated chest pain who have low to intermediate cardiac risk and complete a chest pain observation unit protocol have a less than 1% rate of myocardial infarction in the subsequent 12 months.

Baseline predictors of fatigue 1 year after mild head injury.

OBJECTIVE: To compare reports of fatigue 12 months after minor trauma by participants with mild head injury (MHI) with those with other injury, and identify injury and baseline predictors of fatigue. DESIGN: An inception cohort study of participants with MHI and other nonhead injuries recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months. SETTING: Level II community hospital ED. PARTICIPANTS: Participants (n=58) with MHI and loss of consciousness (LOC) of 30 minutes or less and/or posttraumatic amnesia (PTA) less than 24 hours, 173 with MHI but no PTA/LOC, and 128 with other mild nonhead injuries. INCLUSION CRITERIA: age 18 years or older, within 24 hours of injury, Glasgow Coma Scale score of 13 or higher, and discharge from the ED. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Medical Outcomes Study 36-Item Short-Form Health Survey Vitality subscale. RESULTS: Significant predictors of fatigue severity at 12 months were baseline fatigue, having seen a counselor for a mental health issue, medical disability, marital status, and in some stage of litigation. Injury type was not a significant predictor. CONCLUSIONS: Fatigue severity 12 months after injury is associated with baseline characteristics and not MHI. Clinicians should be cautious about attributing persisting fatigue to MHI without comprehensive consideration of other possible etiologic factors.

Health status, not head injury, predicts concussion symptoms after minor injury.

OBJECTIVE: Postconcussion (PC) syndrome etiology remains poorly understood. We sought to examine predictors of persistent PC symptoms after minor injury. METHODS: Health status, symptom, and injury information were obtained on a sample of patients presenting to the emergency department after minor injury. Postconcussion and cognitive symptoms were assessed at 1, 3, and 12 months. RESULTS: Among 507 patients enrolled, 339 had head injury. Repeated-measures logistic regression modeling of PC and cognitive symptom presence across time indicated that baseline mental health status and physical health status were most predictive of persistent symptoms. In contrast, head injury presence did not predict persistent PC syndrome. DISCUSSION: Baseline mental health status and physical health status were associated with persistent PC syndrome after minor injury, but head injury status was not. Further studies of PC syndrome pathogenesis are needed.

The preventability of trauma-related death at a tertiary hospital in Ghana: a multidisciplinary panel review approach.

INTRODUCTION: The purpose of the study was to determine the preventable trauma-related death rate (PDR) at Komfo Anokye Teaching Hospital in Kumasi, Ghana three years after initiation of an Emergency Medicine (EM) residency. METHOD: This was a retrospective, cross-sectional study. A multidisciplinary panel of physicians completed a structured implicit review of clinical data for trauma patients who died during the period 2011 to 2012. The panel judged the preventability of each death and the nature of inappropriate care. Categories were definitely preventable (DP), possibly preventable (PP), and not preventable (NP). RESULTS: 1) The total number of cases was forty-five; 36 cases had adequate data for review. Subjects were predominately male; road traffic injury (RTI) was the leading mechanism of injury. Four cases (11.1%) were DP, 14 cases (38.9%) were PP and 18 (50%) were NP. Hemorrhage was the leading cause of death (39%). Among DP/PP deaths there were 37 instances of inappropriate care. Delay in surgical intervention was the predominate event (50%). 2) The PDR for this study was 50% (0.95 CI, 33.7%-66.3%). CONCLUSION: Fifty percent of trauma deaths were DP/PP. Multiple episodes of varying types of inappropriate care occurred. More efficient surgical evaluation and appropriate treatment of hemorrhage could reduce trauma morality. Large amounts of missing and incomplete clinical data suggest considerable selection bias. A major implication of this study is the importance of having a robust, prospective trauma registry to collect clinical information to increase the number of cases for review.

Postmortem computed tomography as an adjunct to autopsy for analyzing fatal motor vehicle crash injuries: results of a pilot study.

BACKGROUND: Detailed fatal injury data after fatal motor vehicle crashes (MVC) are necessary to improve occupant safety and promote injury prevention. Autopsy remains the principle source of detailed fatal injury data. However, procedure rates are declining because of a range of technical, ethical, and religious concerns. Postmortem computed tomography (PMCT) is a potential alternative or adjunct to autopsy which is increasingly used by forensic researchers. However, there are only limited data regarding the utility of PMCT for analysis of fatal MVC injuries. METHODS: We performed whole body PMCT and autopsy on six subjects fatally injured in MVC in a single county in Michigan. All injuries detected by either method were coded using the Abbreviated Injury Scale (AIS). Severe injuries, defined as AIS 3 or higher (AIS 3+), were tallied for each forensic procedure to allow a comparison of relative diagnostic performance. RESULTS: A total of 46 AIS 3+ injuries were identified by autopsy and PMCT for these cases. The addition of PMCT to autopsy increased overall detection of AIS 3+ injuries (all types) by 28%. PMCT detected 27% more AIS 3+ skeletal injuries than autopsy but 25% less soft tissue injuries. CONCLUSIONS: Use of PMCT improves the detection of AIS 3+ injuries after fatal MVC compared with isolated use of autopsy and also produces a highly detailed permanent objective record. PMCT appears to improve detection of skeletal injury compared with autopsy but is less sensitive than autopsy for the detection of AIS 3+ soft tissue injuries. Neither autopsy nor PMCT identified all AIS 3+ injuries revealed by the combination of the two methodologies. This suggests that PMCT should be used as an adjunct to autopsy rather than a replacement whenever feasible.

A comprehensive framework for determining the cost of an emergency medical services system.

To determine the cost of an emergency medical services (EMS) system, researchers, policymakers, and EMS providers need a framework with which to identify the components of the system that must be included in any cost calculations. Such a framework will allow for cost comparisons across studies, communities, and interventions. The objective of this article is to present an EMS cost framework. This framework was developed by a consensus panel after analysis of existing peer-reviewed and non-peer-reviewed resources, as well as independent expert input. The components of the framework include administrative overhead, bystander response, communications, equipment, human resources, information systems, medical oversight, physical plant, training, and vehicles. There is no hierarchical rank to these components; they are all necessary. Within each component, there are subcomponents that must be considered. This framework can be used to standardize the calculation of EMS system costs to a community. Standardizing the calculation of EMS cost will allow for comparisons of costs between studies, communities, and interventions.

Diagnostic accuracy of the Kampala Trauma Score using estimated Abbreviated Injury Scale scores and physician opinion.

BACKGROUND: The Kampala Trauma Score (KTS) has been proposed as a triage tool for use in low- and middle-income countries (LMICs). This study aimed to examine the diagnostic accuracy of KTS in predicting emergency department outcomes using timely injury estimation with Abbreviated Injury Scale (AIS) score and physician opinion to calculate KTS scores. METHODS: This was a diagnostic accuracy study of KTS among injured patients presenting to Komfo Anokye Teaching Hospital A&E, Ghana. South African Triage Scale (SATS); KTS component variables, including AIS scores and physician opinion for serious injury quantification; and ED disposition were collected. Agreement between estimated AIS score and physician opinion were analyzed with normal, linear weighted, and maximum kappa. Receiver operating characteristic (ROC) analysis of KTS-AIS and KTS-physician opinion was performed to evaluate each measure's ability to predict A&E mortality and need for hospital admission to the ward or theatre. RESULTS: A total of 1053 patients were sampled. There was moderate agreement between AIS criteria and physician opinion by normal (κ=0.41), weighted (κlin=0.47), and maximum (κmax=0.53) kappa. A&E mortality ROC area for KTS-AIS was 0.93, KTS-physician opinion 0.89, and SATS 0.88 with overlapping 95% confidence intervals (95%CI). Hospital admission ROC area for KTS-AIS was 0.73, KTS-physician opinion 0.79, and SATS 0.71 with statistical similarity. When evaluating only patients with serious injuries, KTS-AIS (ROC 0.88) and KTS-physician opinion (ROC 0.88) performed similarly to SATS (ROC 0.78) in predicting A&E mortality. The ROC area for KTS-AIS (ROC 0.71; 95%CI 0.66-0.75) and KTS-physician opinion (ROC 0.74; 95%CI 0.69-0.79) was significantly greater than SATS (ROC 0.57; 0.53-0.60) with regard to need for admission. CONCLUSIONS: KTS predicted mortality and need for admission from the ED well when early estimation of the number of serious injuries was used, regardless of method (i.e. AIS criteria or physician opinion). This study provides evidence for KTS to be used as a practical and valid triage tool to predict patient prognosis, ED outcomes and inform referral decision-making from first- or second-level hospitals in LMICs.

Economic value of out-of-hospital emergency care: a structured literature review.

STUDY OBJECTIVE: The evaluation of the impact of out-of-hospital emergency care is a relatively new research focus. As such, there is a compelling need to determine how finite health care resources should be used in this setting. The objective of this study is to conduct a structured review of published economic evaluations of out-of-hospital emergency care to assess its economic value. METHODS: A structured literature search and structured review of articles pertaining to the economic value of out-of-hospital care was performed. The bibliographic database MEDLINE was searched for pertinent English-language articles published between 1966 and 2003. The search used the medical subject headings "emergency medical services" and "emergency medical technician" and was limited to the subheading "economics" and crossed with the medical subject heading "economics." The titles generated by this search were systematically reviewed and limited by topic. Abstracts from the identified titles were reviewed to select a final set of pertinent articles. These articles were further limited based on explicit inclusion and exclusion criteria. Authors used a previously published structured evaluation tool to review the final set of identified articles for quality and content. RESULTS: The initial MEDLINE search identified 3,533 citations. From this set, 535 potentially relevant abstracts were reviewed. From the abstract review, 46 articles were identified, along with an additional 14 from searching the secondary references. Of these 60 articles, 32 met the review inclusion criteria and were subjected to a full structured review. These studies predominantly addressed the cost of cardiac arrest (n=13, 41%), major trauma (n=8, 25%), and emergency medical services treatment in general (n=8, 25%). Only 14 studies considered the costs and consequences of competing alternatives. Of these, 2 were cost-benefit and 12 were cost-effectiveness evaluations. Two of the 14 studies met all 10 criteria for high-quality economic evaluation, whereas 2 others met none. CONCLUSION: There is a paucity of out-of-hospital care literature that addresses cost and economic value. The extant literature is limited in scope, poor in quality, and evaluates small subsets of out-of-hospital emergency care costs. Favorable cost-effectiveness has not been firmly established for most aspects of out-of-hospital emergency care.

The efficacy of two brief intervention strategies among injured, at-risk drinkers in the emergency department: impact of tailored messaging and brief advice.

OBJECTIVE: This study used a randomized controlled trial design to compare the effectiveness of four interventions at reducing alcohol consumption, consequences, and heavy episodic drinking among injured, at-risk drinkers in the emergency department (ED). METHOD: Injured patients (n=4,476) completed a computerized survey; 575 at- risk drinkers were randomly assigned to one of four intervention conditions: tailored message booklet with brief advice, tailored message booklet only, generic message booklet with brief advice, and generic message booklet only. Regression models using the generalized estimating equation approach were constructed comparing the intervention conditions at baseline, 3-month follow-up, and 12-month follow-up. Gender and age were entered in models along with their interaction. RESULTS: Each of the intervention groups significantly decreased their alcohol consumption from baseline to 12-month follow-up; subjects in the tailored message booklet with brief advice group significantly decreased their average weekly alcohol consumption by 48.5% (p<.0001). Those in the brief advice conditions (tailored or generic) significantly decreased their average consumption during the 12 months of the study compared with the no brief advice conditions. Younger adult women (ages 19-22) who received some brief advice were the most likely to decrease their heavy episodic drinking. CONCLUSIONS: This was the first large-scale, brief intervention trial that included development and testing of computerized, highly tailored interventions with injured drinkers in the ED. ED-based interventions for alcohol problems would benefit from computerized screening, brief advice, and booklets to positively impact risky drinking practices.

Training emergency medicine nurses and physicians in youth violence prevention.

Adolescents seen in an urban Emergency Department (ED) are more likely to die from violence than from any other illness or condition for which they seek care in the ED. Most injured patients presenting to our nation's EDs are treated and released, even after a firearm-related injury. These youth who are discharged from the ED will not interface with resources on the inpatient trauma unit. The current standard of care in the ED involves no referral for violence-related prevention services. Despite the fact that ED physicians and nurses frequently medically manage victims of violent assault, there are few courses on youth violence prevention (YVP) framed from the viewpoint of emergency healthcare providers, and ED staff remain relatively uneducated as a specialty on the identification, assessment, and referral resources available for early intervention and prevention. This article focuses on the development and in-depth description of a case-based, 1-hour continuing medical education presentation for ED physicians, residents, and nursing staff on YVP. This presentation is aimed to increase awareness of the role of ED personnel in YVP and to provide basic knowledge and skills needed to begin to incorporate YVP into routine clinical practice in an Emergency Department setting.

A randomized controlled trial of an emergency department-based interactive computer program to prevent alcohol misuse among injured adolescents.

STUDY OBJECTIVE: To determine whether an emergency department (ED)-based laptop computer intervention reduces the normative age-related increase in alcohol misuse compared with standard of care. METHODS: This was a randomized controlled trial conducted from October 11, 1999, to April 14, 2001, in a community teaching hospital and university medical center. Subjects were aged 14 to 18 years and with a minor injury. Controls and intervention participants completed a computer-based questionnaire. Intervention participants also completed a laptop-based interactive computer program to affect alcohol misuse. Main outcome measures were Alcohol Misuse Index (Amidx) and binge-drinking episodes. Follow-up occurred by telephone at 3 and 12 months. Analysis included repeated-measures analysis of variance (alpha=0.05; power 0.80; effect size 0.10). RESULTS: Three hundred twenty-nine participants were randomized to the intervention group, and 326 participants were randomized to the control group. Two hundred ninety-five (89.7%) intervention subjects and 285 (87.4%) control subjects completed 3- and 12-month follow-ups. For intervention and control groups, respectively, mean age was 16.0 and 15.9 years and men composed 66.8% and 66.3% of the groups; Amidx scores were 2.2 and 2.0; binge-drinking episodes were 1.2 and 1.0. Outcomes for intervention and control, respectively, were Amidx (3 months) 1.5 and 1.4; Amidx (12 months) 1.8 and 2.1; binge drinking (3 months) 0.9 and 0.8; and binge drinking (12 months) 1.4 and 1.2. Overall, there were no significant effects (effect size 0.04). No detrimental effects were noted. Subgroup analysis suggested that the intervention may have an effect among subjects with experience drinking and driving (5% of the sample). CONCLUSION: The intervention was not effective in decreasing alcohol misuse among the study population. Further research will be required to determine effectiveness among the subgroup of adolescent minor injury patients who have experience drinking and driving.

The relationship of blood alcohol concentration to impairment severity in spinal cord injury.

OBJECTIVE: To investigate the relationship between blood alcohol concentration (BAC) and severity of neurological impairment. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Subjects with traumatic spinal cord injury (SCI; N = 119) with dates of injury between 1991 and 2000 who received their acute treatment at a midwestern Model SCI Care System and for whom information regarding BAC was available. MAIN OUTCOME MEASURE: severity of neurological impairment. Data were analyzed using chi2 tests and analysis of variance (ANOVA). RESULTS: A significant association was observed between impairment severity and BAC. CONCLUSIONS: The study suggests that alcohol consumption is associated with severity of SCI. A more rigorous study controlling for trauma attributes is necessary to confirm these results and appraise whether alcohol has a potentiating effect on impairment. If borne out, the study's findings may lead to alterations in emergency room procedures and to changes in public health and education efforts resulting from a reframing of the issue of safe consumption of alcohol.

Analysis of the Nature of IRB Contingencies Required for Informed Consent Document Approval.

The University of Michigan Human Research Protection Program formed a six-member committee to analyze the nature of Institutional Review Board (IRB) staff and board contingencies for the approval of informed consent documents. Of the 100 studies examined, 87% had one or more informed consent contingencies. "Omissions" in documentation (40%) and "better clarity" (24%) accounted for the majority, while "word-smithing" accounted for only 10%. This is one of the first studies to examine the nature of IRB contingencies as they relate to informed consent documents. Educational efforts targeting completeness in documentation and clarity on the part of study teams, and discouraging "word-smithing" on the part of IRBs, could reduce the number of informed consent contingencies and expedite the IRB approval process.

Violence and substance use among an injured emergency department population.

OBJECTIVES: This study evaluated a sample of emergency department (ED) patients for history of violence and substance abuse. METHODS: Injured patients (n = 320) completed questionnaires (14% refusal rate) during a visit to a Level 1 urban ED after an acute injury. Specific questions were asked regarding whether the injury was related to acute violence (AV), whether there was past-year violence history (VH), including violence victimization and perpetration in both partner and nonpartner relationships, as well as any substance use in the past month and any substance-related consequences in the past year. RESULTS: Fourteen percent of the participants presented with an AV-related injury, and 53% reported VH. Most AV patients (89%) reported VH. No significant differences were found between the participants with AV and VH in demographic, substance use, or substance-related consequences. The AV and VH groups were combined (V), with analyses comparing these participants with those without AV and VH. Men were significantly more likely than women to report V (odds ratio = 2.0). V was significantly related to substance use and substance-related consequences. For example, in comparison with the participants reporting no alcohol or drug use, those reporting illicit drug use were 6.2 times as likely to report V, and those drinking any alcohol only were 2.0 times as likely to report V. CONCLUSIONS: A large percentage of injured patients in this urban ED experienced violence in the past year. Alcohol and illicit drugs appear to be concomitant with violence.

Guidelines for the management of severe head injury: are emergency physicians following them?

UNLABELLED: The Brain Trauma Foundation published "Guidelines for the Management of Severe Head Injury" in 1995. These evidence-based clinical guidelines (CGs) recommended against prophylactic hyperventilation and glucocorticoid use and advocated for aggressive blood pressure (BP) resuscitation, and the careful use of mannitol. OBJECTIVE: To survey Michigan emergency physicians (MEPs) to test their adherence to these guidelines. METHODS: An anonymous mail survey was sent to all 566 MEPs who are members of the American College of Emergency Physicians. Three clinical scenarios involving severe head injury were presented, all with Glasgow Coma Scale (GCS) scores of 8 or less. The physicians were asked to choose from 15 diagnostic and treatment options, which included: intubation and hyperventilation, BP resuscitation, intravenous (IV) mannitol administration, and IV glucocorticoid administration. RESULTS: Three hundred nineteen (56%) surveys were returned. Forty-six percent [95% confidence interval (95% CI) = 40% to 51%] of the MEPs elected to use prophylactic hyperventilation; very few administered IV glucocorticoids. Seventy-eight percent (95% CI = 75% to 81%) corrected hypotension with systolic BP < 90 mm Hg; 83% (95% CI = 80% to 86%) also administered mannitol appropriately. CONCLUSIONS: A majority of MEPs are managing severe head injury patients in accordance with the "Guidelines for the Management of Severe Head Injury," with the exception of avoiding prophylactic hyperventilation. More education and/or exposure to the evidence regarding prophylactic hyperventilation of severely head injured patients may improve adherence to the guidelines.