Prevalence of Blood-Borne Viruses and Predictors of Risk in Potential Organ Donors in Australia.

Internationally, the designation of a patient as an increased viral risk organ donor has been associated with lower utilisation rates. The actual prevalence of blood borne viruses in Australian potential organ donors, and the predictive performance of questionnaires administered to stratify this risk, remains unknown. We conducted a retrospective review of all patients who commenced workup for donation on the national database between 2014-2020. The prevalence of HIV, Active HBV and Active HCV in 3650 potential organ donors was 0.16%, 0.9%, and 2.2%, respectively. The behavioural risk profile was assessed in a subset of 3633 patients. Next-of-kin reported increased risk behaviours were associated with an increased prevalence of HCV but not of HIV or HBV (OR 13.8, p < 0.01, OR 0.3. p = 0.42, OR 1.5, p = 0.14). Furthermore, the majority of HIV and HBV infections occurred in potential donors without a disclosed history of increased risk behaviours. In this series, donors had a higher prevalence of HCV, and similar rates of HBV and HIV to the broader community. Behavioural transmission risks were poorly predictive of HIV and HBV. Rather than pre-transplantation behavioural risk screening, routine post-transplant recipient screening may provide a more powerful tool in mitigating the consequences of unexpected viral transmission.

Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial.

STUDY OBJECTIVE: We aim to determine the most efficacious of 3 common medication regimens for the sedation of acutely agitated emergency department (ED) patients. METHODS: We undertook a randomized, controlled, double-blind, triple-dummy, clinical trial in 2 metropolitan EDs between October 2014 and August 2015. Patients aged 18 to 65 years and requiring intravenous medication sedation for acute agitation were enrolled and randomized to an intravenous bolus of midazolam 5 mg-droperidol 5 mg, droperidol 10 mg, or olanzapine 10 mg. Two additional doses were administered, if required: midazolam 5 mg, droperidol 5 mg, or olanzapine 5 mg. The primary outcome was the proportion of patients adequately sedated at 10 minutes. RESULTS: Three hundred forty-nine patients were randomized to the 3 groups. Baseline characteristics were similar across the groups. Ten minutes after the first dose, significantly more patients in the midazolam-droperidol group were adequately sedated compared with the droperidol and olanzapine groups: differences in proportions 25.0% (95% confidence interval [CI] 12.0% to 38.1%) and 25.4% (95% CI 12.7% to 38.3%), respectively. For times to sedation, the differences in medians between the midazolam-droperidol group and the droperidol and olanzapine groups were 6 (95% CI 3 to 8) and 6 (95% CI 3 to 7) minutes, respectively. Patients in the midazolam-droperidol group required fewer additional doses or alternative drugs to achieve adequate sedation. The 3 groups' adverse event rates and lengths of stay did not differ. CONCLUSION: Midazolam-droperidol combination therapy is superior, in the doses studied, to either droperidol or olanzapine monotherapy for intravenous sedation of the acutely agitated ED patient.

Implementation research in emergency medicine: a systematic scoping review.

INTRODUCTION: Implementation research aims to increase the uptake of research findings into clinical practice to improve the quality of healthcare. This scoping systematic study aims to assess the volume and scope of implementation research in emergency medicine (EM) to obtain an overview and inform future implementation research. METHODS: Studies were identified by searching electronic databases and reference lists of included studies for the years 2002, 2007 and 2012. Titles/abstracts were screened, full papers checked and data extracted by one author, with a random sample checked by a second author. RESULTS: A total of 3581 citations were identified with 197 eligible papers included. The number of papers significantly increased over time from 26 in 2002 to 77 in 2007 and 94 in 2012 (p<0.05). Eighty-two (42%) focused on identifying evidence-practice gaps, 77 (39%) evaluated the effectiveness of implementation interventions and 38 (19%) explored barriers and enablers to change. Only two papers explicitly stated that theory was used. Five of the 77 effectiveness studies used a randomised design and few provided sufficient detail about the intervention undergoing evaluation. CONCLUSIONS: Although there was a significant increase in the number of implementation research papers, most studies focused on identifying evidence-practice gaps or used weak study designs to evaluate the effects of implementation interventions. Recommendations for improving implementation research in EM include identifying barriers and enablers to implementation, using theory in areas where proven important gaps exist, improving the reporting of the content of interventions and using rigorous study designs to evaluate their effectiveness.

Effectiveness of pharmacological treatments for severe agitation in real-world emergency settings: protocol of individual-participant-data network meta-analysis.

BACKGROUND: Severe psychomotor agitation and aggression often require immediate pharmacological intervention, but clear evidence-based recommendations for choosing among the multiple options are lacking. To address this gap, we plan a systematic review and individual-participant-data network meta-analysis to investigate their comparative effectiveness in real-world emergency settings with increased precision. METHODS: We will include randomized controlled trials investigating intramuscular or intravenous pharmacological interventions, as monotherapy or in combination, in adults with severe psychomotor agitation irrespective of the underlying diagnosis and requiring rapid tranquilization in general or psychiatric emergency settings. We will exclude studies before 2002, those focusing on specific reasons for agitation and placebo-controlled trials to avoid concerns related to the transitivity assumption and potential selection biases. We will search for eligible studies in BIOSIS, CENTRAL, CINAHL Plus, Embase, LILACS, MEDLINE via Ovid, PubMed, ProQuest, PsycINFO, ClinicalTrials.gov, and WHO-ICTRP. Individual-participant data will be requested from the study authors and harmonized into a uniform format, and aggregated data will also be extracted from the studies. At least two independent reviewers will conduct the study selection, data extraction, risk-of-bias assessment using RoB 2, and applicability evaluation using the RITES tool. The primary outcome will be the number of patients achieving adequate sedation within 30 min after treatment, with secondary outcomes including the need for additional interventions and adverse events, using odds ratios as the effect size. If enough individual-participant data will be collected, we will synthesize them in a network meta-regression model within a Bayesian framework, incorporating study- and participant-level characteristics to explore potential sources of heterogeneity. In cases where individual-participant data are unavailable, potential data availability bias will be explored, and models allowing for the inclusion of studies reporting only aggregated data will be considered. We will assess the confidence in the evidence using the Confidence in Network Meta-Analysis (CINeMA) approach. DISCUSSION: This individual-participant-data network meta-analysis aims to provide a fine-tuned synthesis of the evidence on the comparative effectiveness of pharmacological interventions for severe psychomotor agitation in real-world emergency settings. The findings from this study can greatly be provided clearer evidence-based guidance on the most effective treatments. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023402365.

Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial.

STUDY OBJECTIVE: Parenteral benzodiazepines or antipsychotics are often used to manage acute agitation in emergency department (ED) settings in which alternative strategies have failed or are not feasible. There are scant data comparing parenteral medication regimens. We aim to determine the efficacy and safety of intravenous droperidol or olanzapine as an adjunct to intravenous midazolam for rapid patient sedation. METHODS: We undertook a randomized, double-blind, placebo-controlled, double-dummy, clinical trial in 3 EDs (August 2009 to March 2011). Adult patients (n=336) requiring intravenous drug sedation for acute agitation were randomized to receive a saline solution (control), droperidol (5 mg), or olanzapine (5 mg) bolus. This was immediately followed by incremental intravenous midazolam boluses (2.5 to 5 mg) until sedation was achieved. The primary outcome was time to sedation. Secondary outcomes were need for "rescue" drugs and adverse events. RESULTS: Three hundred thirty-six patients were randomized to the 3 groups. Baseline characteristics were similar across groups. The differences in medians for times to sedation between the control and droperidol and control and olanzapine groups were 4 minutes (95% confidence interval [CI] 1 to 6 minutes) and 5 minutes (95% CI 1 to 6 minutes), respectively. At any point, patients in the droperidol and olanzapine groups were approximately 1.6 times more likely to be sedated compared with controls: droperidol and olanzapine group hazard ratios were 1.61 (95% CI 1.23 to 2.11) and 1.66 (95% CI 1.27 to 2.17), respectively. Patients in the droperidol and olanzapine groups required less rescue or alternative drug use after initial sedation. The 3 groups' adverse event profiles and lengths of stay did not differ. CONCLUSION: Intravenous droperidol or olanzapine as an adjunct to midazolam is effective and decreases the time to adequate sedation compared with midazolam alone.

Electronic error-reporting systems: a case study into the impact on nurse reporting of medical errors.

BACKGROUND: Underreporting of errors in hospitals persists despite the claims of technology companies that electronic systems will facilitate reporting. This study builds on previous analyses to examine error reporting by nurses in hospitals using electronic media. PURPOSE: This research asks whether the electronic media creates additional barriers to error reporting, and, if so, what practical steps can all hospitals take to reduce these barriers. METHOD: This is a mixed-method case study nurses' use of an error reporting system, RiskMan, in two hospitals. The case study involved one large private hospital and one large public hospital in Victoria, Australia, both of which use the RiskMan medical error reporting system. CONCLUSION: Information technology-based error reporting systems have unique access problems and time demands and can encourage nurses to develop alternative reporting mechanisms. This research focuses on nurses and raises important findings for hospitals using such systems or considering installation. This article suggests organizational and technical responses that could reduce some of the identified barriers.

Management of paediatric acute severe behavioural disturbance in emergency departments across Australia: A PREDICT survey of senior medical staff.

OBJECTIVE: Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in EDs. It poses a significant risk to the patient and those around them. Little is known about the epidemiology or most effective management in the paediatric population. The aim of the present study is to clarify the practice of senior emergency doctors in Australia when managing paediatric ASBD. METHODS: The present study was a voluntary electronic questionnaire distributed to and undertaken by senior medical staff in EDs affiliated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network. Respondents reported on exposure to and confidence in managing paediatric ASBD and their current practices. RESULTS: A total of 227 (33%) clinicians completed the survey between February and May 2020. Most clinicians were caring for at least two young people with ASBD each week (72%), felt confident regarding the majority of components of management and referred to local clinical practice guidelines (69%). Agitation/sedation rating scales were seldom used (19%). There was a significant variation in self-reported management practices. The choice of whether to use medication at all, the medication chosen and route of administration all varied greatly. Respondents were more willing to provide parenteral medication to young people reported as having recreational drug intoxication (84%) than those with neurodevelopment disorders (65%) when the same degree of agitation was reported. CONCLUSIONS: Within Australia, there is considerable variation in paediatric ASBD practice, in particular regarding medication provision. Further prospective research is required to inform best clinical practice.

Recently Acquired Blood-borne Virus Infections in Australian Deceased Organ Donors: Estimation of the Residual Risk of Unexpected Transmission.

Unexpected donor-derived infections of hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV are rare but important potential complications of deceased organ transplantation. The prevalence of recently acquired (yield) infections has not been previously described in a national cohort of Australian deceased organ donors. Donor yield infections are of particularly significance, as they can be used to gain insights in the incidence of disease in the donor pool and in turn, estimate the risk of unexpected disease transmission to recipients. Methods: We conducted a retrospective review of all patients who commenced workup for donation in Australia between 2014 and 2020. Yield cases were defined by having both unreactive serological screening for current or previous infection and reactive nucleic acid testing screening on initial and repeat testing. Incidence was calculated using a yield window estimate and residual risk using the incidence/window period model. Results: The review identified only a single yield infection of HBV in 3724 persons who commenced donation workup. There were no yield cases of HIV or HCV. There were no yield infections in donors with increased viral risk behaviors. The prevalence of HBV, HCV, and HIV was 0.06% (0.01-0.22), 0.00% (0-0.11), and 0.00% (0-0.11), respectively. The residual risk of HBV was estimated to be 0.021% (0.001-0.119). Conclusions: The prevalence of recently acquired HBV, HCV, and HIV in Australians who commence workup for deceased donation is low. This novel application of yield-case-methodology has produced estimates of unexpected disease transmission which are modest, particularly when contrasted with local average waitlist mortality. Supplemental Visual Abstract; http://links.lww.com/TXD/A503.

Pharmacological Emergency management of Agitation in Children and Young people: protocol for a randomised controlled trial of intraMuscular medication (PEAChY-M).

INTRODUCTION: Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in emergency departments (EDs) in adults and young people. Despite the increasing number of presentations and significant associated risks to patients, families and caregivers, there is limited evidence to guide the most effective pharmacological management in children and adolescents. The aim of this study is to determine whether a single dose of intramuscular olanzapine is more effective than intramuscular droperidol at successfully sedating young people with ASBD requiring intramuscular sedation. METHODS AND ANALYSIS: This study is a multicentre, open-label, superiority randomised controlled trial. Young people aged between 9 and 17 years and 364 days presenting to an ED with ASBD who are deemed to require medication for behavioural containment will be recruited to the study. Participants will be randomised in a 1:1 allocation between a single weight-based dose of intramuscular olanzapine and intramuscular droperidol. The primary outcome is the proportion of participants who achieve successful sedation at 1-hour post randomisation without the need for additional sedation. Secondary outcomes will include assessing for adverse events, additional medications provided in the ED, further episodes of ASBD, length of stay in the ED and hospital and satisfaction with management.Effectiveness will be determined using an intention-to-treat analysis, with medication efficacy determined as part of the secondary outcomes using a per-protocol analysis. The primary outcome of successful sedation at 1 hour will be presented as a percentage within each treatment group, with comparisons presented as a risk difference with its 95% CIs. ETHICS AND DISSEMINATION: Ethics approval was received from the Royal Children's Hospital Human Research Ethics Committee (HREC/69948/RCHM-2021). This incorporated a waiver of informed consent for the study. The findings will be disseminated in a peer-reviewed journal and at academic conferences. TRIAL REGISTRATION NUMBER: ACTRN12621001238864.

Pharmacological emergency management of agitation in children and young people: protocol for a randomised controlled trial of oral medication (PEAChY-O).

INTRODUCTION: Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in emergency departments (EDs) in adults and young people. Despite the increasing number of presentations and significant associated risks to patients, families and caregivers, there is limited evidence to guide the most effective pharmacological management in children and adolescents. The aim of this study is to determine whether a single dose of oral olanzapine is more effective than a dose of oral diazepam at successfully sedating young people with ASBD. METHODS AND ANALYSIS: This study is a multicentre, open-label, superiority randomised controlled trial. Young people aged between 9 years and 17 years and 364 days presenting to an ED with ASBD who are deemed to require medication for behavioural containment will be recruited to the study. Participants will be randomised in a 1:1 allocation between a single weight-based dose of oral olanzapine and oral diazepam. The primary outcome is the proportion of participants who achieve successful sedation at 1-hour post randomisation without the need for additional sedation. Secondary outcomes will include assessing for adverse events, additional medications provided in the ED, further episodes of ASBD, length of stay in the ED and hospital and satisfaction with management.Effectiveness will be determined using an intention-to-treat analysis, with medication efficacy determined as part of the secondary outcomes using a per-protocol analysis. The primary outcome of successful sedation at 1 hour will be presented as a percentage within each treatment group, with comparisons presented as a risk difference with its 95% CIs. ETHICS AND DISSEMINATION: Ethics approval was received from the Royal Children's Hospital Human Research Ethics Committee (HREC/66478/RCHM-2020). This incorporated a waiver of informed consent for the study. The findings will be disseminated in a peer-reviewed journal and at academic conferences. TRIAL REGISTRATION NUMBER: ACTRN12621001236886.

Mandatory pain scoring at triage reduces time to analgesia.

STUDY OBJECTIVE: We study whether mandatory triage pain scoring and an educational program reduces the time to initial analgesic treatment. METHODS: We performed a prospective interventional study in the emergency department (ED) of an adult tertiary referral hospital and major trauma center. After an observational assessment of baseline time to analgesic administration, we mandated the recording of triage pain scores through our computerized information system. In a second separate phase, we administered a staff educational package on the importance of timely analgesia. We measured time to initial analgesia after each phase and at 12-month follow-up. RESULTS: We studied 35,628 patients (8,743 baseline, 8,462 after mandating pain scoring, 9,043 after the educational program, and 9,380 at follow-up), with 12,925 patients (36.3%) overall receiving analgesics. At baseline, the median time to analgesia was 123 minutes (interquartile range [IQR] 58 to 231 minutes), which reduced with pain scoring (95 minutes; IQR 45 to 194 minutes) but no further with the educational package (98 minutes; IQR 45 to 191 minutes). At 12-month follow-up, the median time to analgesia was 78 minutes (IQR 45 to 143 minutes), 45 minutes (36.4%) faster than at baseline. CONCLUSION: The simple act of altering our ED computerized information system to require pain scoring at triage led to substantially faster provision of initial analgesia, with the effect sustained at 12 months.

Remote COVID-19 patient monitoring system: a qualitative evaluation.

BACKGROUND: Many COVID-19 patients are discharged home from hospital with instructions to self-isolate. This reduces the burden on potentially overwhelmed hospitals. The Royal Melbourne Hospital (RMH) Home Monitoring Programme (HMP) is a model of care for COVID-19 patients which chiefly tracks pulse oximetry and body temperature readings. OBJECTIVE: To evaluate the feasibility and acceptability of the HMP from a patient perspective. DESIGN, SETTINGS AND PARTICIPANTS: Of 46 COVID-19 patients who used the HMP through RMH during April to August 2020, 16 were invited to participate in this qualitative evaluation study; all accepted, including 6 healthcare workers. Attempts were made to recruit a gender-balanced sample across a range of COVID-19 severities and comorbidities. Participants completed a brief semistructured phone interview discussing their experience of using the HMP. OUTCOME MEASURES AND ANALYSIS: A thematic analysis of interview data was conducted. Feasibility was defined as the HMP's reported ease of use. Acceptability was considered holistically by reviewing themes in the interview data. RESULTS: The HMP allowed clinical deterioration to be recognised as it occurred enabling prompt intervention. All participants reported a positive opinion of the HMP, stating it was highly acceptable and easy to use. Almost all participants said they found using it reassuring. Patients frequently mentioned the importance of the monitoring clinicians as an information conduit. The most suggested improvement was to monitor a broader set of symptoms. CONCLUSIONS: The HMP is highly feasible and acceptable to patients. This model of care could potentially be implemented on a mass-scale to reduce the burden of COVID-19 on hospitals. A key benefit of the HMP is the ability to reassure patients they will receive suitable intervention should they deteriorate while isolating outside of hospital settings.

Outcomes of laceration suture repair in the emergency department.

OBJECTIVE: To assess patient satisfaction with laceration management, post-ED care, cosmesis and complication rates. METHODS: We undertook a prospective observational study of adult patients with lacerations sutured in two EDs over a 4-month period. ED data included participant demographics, laceration characteristics and management. A telephone survey was undertaken approximately 14 days post-ED discharge. Patient satisfaction with post-ED pain management, advice on wound care and follow up, overall management and wound cosmesis were evaluated using a six-item satisfaction scale (very dissatisfied to very satisfied). Details of wound infection, dehiscence and suture failure were recorded. RESULTS: Eighty-nine patients participated. The number (% [95% confidence interval]) of patients very satisfied with their laceration management were: post-ED pain management 55 (62.5% [51.5-72.4]), wound care advice 51 (57.3% [46.4-67.6]), follow-up advice 39 (43.8% [33.5-54.7]), overall management 61 (68.5% [57.7-77.7]) and cosmetic appearance 46 (51.7% [40.9-62.3]). Infection, dehiscence and suture failure occurred in 5 (5.6%), 8 (9.0%) and 8 (9.0%) cases, respectively. These complications were not associated with being very satisfied overall (P = 0.96). Patients very satisfied with post-ED pain management, wound care advice, follow-up advice or wound cosmesis were much more likely to be very satisfied overall (P < 0.001). CONCLUSIONS: Most patients are very satisfied with their laceration management. However, there is scope for improvement, especially for follow-up and wound care advice. Complications are infrequent and not associated with overall satisfaction.

Relation of substance use disorders to mortality, accident and emergency department attendances, and hospital admissions: A 13-year population-based cohort study in Hong Kong.

BACKGROUND: The impact of substance use disorders (SUD) in an Asian population has not been fully explored. We aimed to assess the risk of mortality, accident and emergency (A&E) department attendances, and hospital admissions associated with SUD in a population-based cohort study. METHOD: Patients diagnosed with SUD in public A&E departments from 2004 to 2016 (N = 8,423) were identified in the Clinical Database Analysis and Reporting System of the Hong Kong Hospital Authority and 1:1 matched to patients without SUD by propensity score (N = 6,074 in each group). Relative risks of mortality, A&E attendances and hospital admissions were assessed using Cox regression and Hurdle negative binomial regression. RESULTS: Patients with SUD had higher mortality (hazard ratio=1.43; 95% confidence interval [CI]=1.26-1.62) and more often died from poisoning or toxicity and injuries. The odds ratio (OR) for A&E attendances and all-cause hospital admissions associated with SUD were 2.80 (95% CI=2.58-3.04) and 3.54 (95% CI=3.26-3.83), respectively. The impact of SUD on the above outcomes was greatest among school-aged individuals (≤ 21 years) and decreased with age. The relative risk of mental disorder-related hospital admissions was much higher than that for infections, respiratory diseases, and cardiovascular diseases. In patients with SUD, ketamine and amphetamine use were associated with increased A&E attendances than opioid use. CONCLUSIONS: SUD was associated with increased mortality, A&E attendances and hospital admissions, especially in school-aged individuals. Our findings suggest prioritising early treatment and preventive interventions for school-aged individuals and focusing on the management of comorbid mental disorders and the use of ketamine and amphetamine.

Threat of COVID-19 impacting on a quaternary healthcare service: a retrospective cohort study of administrative data.

OBJECTIVES: The threat of a pandemic, over and above the disease itself, may have significant and broad effects on a healthcare system. We aimed to describe the impact of the SARS-CoV-2 pandemic (during a relatively low transmission period) and associated societal restrictions on presentations, admissions and outpatient visits. DESIGN: We compared hospital activity in 2020 with the preceding 5 years, 2015-2019, using a retrospective cohort study design. SETTING: Quaternary hospital in Melbourne, Australia. PARTICIPANTS: Emergency department presentations, hospital admissions and outpatient visits from 1 January 2015 to 30 June 2020, n=896 934 episodes of care. INTERVENTION: In Australia, the initial peak COVID-19 phase was March-April. PRIMARY AND SECONDARY OUTCOME MEASURES: Separate linear regression models were fitted to estimate the impact of the pandemic on the number, type and severity of emergency presentations, hospital admissions and outpatient visits. RESULTS: During the peak COVID-19 phase (March and April 2020), there were marked reductions in emergency presentations (10 389 observed vs 14 678 expected; 29% reduction; p<0.05) and hospital admissions (5972 observed vs 8368 expected; 28% reduction; p<0.05). Stroke (114 observed vs 177 expected; 35% reduction; p<0.05) and trauma (1336 observed vs 1764 expected; 24% reduction; p<0.05) presentations decreased; acute myocardial infarctions were unchanged. There was an increase in the proportion of hospital admissions requiring intensive care (7.0% observed vs 6.0% expected; p<0.05) or resulting in death (2.2% observed vs 1.5% expected; p<0.05). Outpatient attendances remained similar (30 267 observed vs 31 980 expected; 5% reduction; not significant) but telephone/telehealth consultations increased from 2.5% to 45% (p<0.05) of total consultations. CONCLUSIONS: Although case numbers of COVID-19 were relatively low in Australia during the first 6 months of 2020, the impact on hospital activity was profound.

Intramuscular midazolam, olanzapine, or haloperidol for the management of acute agitation: A multi-centre, double-blind, randomised clinical trial.

BACKGROUND: The safety and effectiveness of intramuscular olanzapine or haloperidol compared to midazolam as the initial pharmacological treatment for acute agitation in emergency departments (EDs) has not been evaluated. METHODS: A pragmatic, randomised, double-blind, active-controlled trial was conducted from December 2014 to September 2019, in six Hong Kong EDs. Patients (aged 18-75 years) with undifferentiated acute agitation requiring parenteral sedation were randomised to 5 mg intramuscular midazolam (n = 56), olanzapine (n = 54), or haloperidol (n = 57). Primary outcomes were time to adequate sedation and proportion of patients who achieved adequate sedation at each follow-up interval. Sedation levels were measured on a 6-level validated scale (ClinicalTrials.gov Identifier: NCT02380118). FINDINGS: Of 206 patients randomised, 167 (mean age, 42 years; 98 [58·7%] male) were analysed. Median time to sedation for IM midazolam, olanzapine, and haloperidol was 8·5 (IQR 8·0), 11·5 (IQR 30·0), and 23·0 (IQR 21·0) min, respectively. At 60 min, similar proportions of patients were adequately sedated (98%, 87%, and 97%). There were statistically significant differences for time to sedation with midazolam compared to olanzapine (p = 0·03) and haloperidol (p = 0·002). Adverse event rates were similar across the three arms. Dystonia (n = 1) and cardiac arrest (n = 1) were reported in the haloperidol group. INTERPRETATION: Midazolam resulted in faster sedation in patients with undifferentiated agitation in the emergency setting compared to olanzapine and haloperidol. Midazolam and olanzapine are preferred over haloperidol's slower time to sedation and potential for cardiovascular and extrapyramidal side effects. FUNDING: Research Grants Council, Hong Kong.

Conference presentations: A research primer for low- and middle-income countries.

Presenting research at a conference is an opportunity to disseminate the findings, network with other researchers, and to develop your academic track record. Although every conference will have some local differences, there are common approaches to presenting your research in the best manner. This will differ depending on whether it is an oral or a poster presentation. This research primer aims to support researchers in the early stages of their careers to undertake the best possible presentation.

Prevalence of illicit substance use among patients presenting to the emergency department with acute behavioural disturbance: Rapid point-of-care saliva screening.

OBJECTIVE: To determine the prevalence of illicit substance use among patients presenting to one ED with acute behavioural disturbance using point-of-care saliva testing. METHODS: A prospective observational study was conducted. Acute behavioural disturbance was defined as any episode requiring a security response for unarmed threat (Code Grey). The setting was a single ED and tertiary referral centre located in metropolitan Australia. Participants were adults presenting to the ED requiring a Code Grey. Saliva was analysed for meth/amphetamine, cannabis, cocaine and opiates using a rapid point-of-care test. Self-reported drug use was recorded at the time of saliva testing. Data collection occurred between August 2016 and March 2017. RESULTS: There were 229 valid saliva samples. Participants were, on average, 35 years (range 18-72) and male (168/229; 73%). Forty percent (95% confidence interval 34-47) of samples tested positive, with 20% positive for two or more substances. Meth/amphetamines was detected in 92% of positive samples, 17% of samples tested positive for opiates, 8% for cannabis and 7% for cocaine. Among participants, 19% self-reported current substance use and 20% reported using illicit substances within the past 24 h. CONCLUSIONS: The prevalence of illicit substance use among this cohort was 40%. Self-reporting was unreliable. Point-of-care saliva testing is feasible. Early identification of harmful drug use may assist clinical decision making in selected or undifferentiated cases and provide an opportunity to implement harm minimisation strategies and make referrals.

Amphetamine-type stimulant use among patients admitted to the emergency department behavioural assessment unit: Screening and referral outcomes.

Amphetamine-type stimulant use, including methamphetamine, amphetamine, and 3,4-methylenedioxymethamphetamine, is associated with a range of behavioural symptoms. Screening for amphetamine-type stimulant use among people presenting to the emergency department with behavioural disturbance and referral to treatment has not been evaluated. The objective of this study was to determine the prevalence of amphetamine-type stimulant use among patients admitted to a behavioural assessment unit and report referral outcomes. A prospective observational design was used. Individuals who tested positive or self-reported amphetamine-type stimulant use were referred to the alcohol and other drug clinician. We measured the prevalence of amphetamine-type stimulant use in saliva and by self-report along with rates of referral. The setting was a behavioural assessment unit located within an Australian emergency department. Admitted adults were enrolled from July to December 2017. Those who tested positive or self-reported amphetamine-type stimulant use were provided with harm reduction advice and offered referral. Four hundred and seventy-two tests were performed. Fifteen were excluded due to invalid results or redundant enrolment. Of the 457 individuals, 59% were male, with a mean age of 35 years (SD 13). Fifty-three (11.6%, 95% CI: 8.9-15.0) tested positive for amphetamine-type stimulants. Of those with a negative test, 44 (9.6%, 95% CI: 7.3-12.7) self-reported amphetamine-type stimulant use in the previous 24 hours. The prevalence of amphetamine-type stimulant use was 21.2% (95% CI: 17.7-25.2). Most accepted referral to the alcohol and other drug clinician (85.6%, 95% CI 77.2-91.2). The emergency visit represents a window of opportunity for screening for amphetamine-type stimulant use and initiating referrals.