Prevalence & Correlates of Transactional Sex among an Urban Emergency Department Sample: Exploring Substance Use & HIV Risk

Men and women involved in transactional sex (TS) report increased rates of HIV risk behaviors and substance use problems as compared with the general population. When people engaged in TS seek health care, they may be more likely to utilize the emergency department (ED) rather than primary care services. 

Our goal was to examine the prevalence and correlates of TS involvement among an ED sample of men and women. Adults ages 18-60 were recruited from an urban ED, as part of a larger randomized control trial. Participants (n = 4,575; 3,045 women, 1,530 men) self-administered a screening survey that assessed past 3-month substance use (including alcohol, marijuana, illicit drugs, and prescription drugs) and HIV risk behaviors, including TS (i.e., being paid in exchange of a sexual behavior), inconsistent condom use, multiple partners, and anal sex. 

Of the sample, 13.3% (n = 610) reported TS within the past 3 months (64.4% were female). Bivariate analysis showed TS was significantly positively associated with alcohol use severity, marijuana use, and both illicit and prescription drug use, and multiple HIV risk behaviors. These variables (except marijuana) remained significantly positively associated with TS in a binary logistic regression analysis. 

The prevalence of recent TS involvement among both male and female ED patients is substantial. These individuals were more likely to report higher levels of alcohol/drug use and HIV risk behaviors. 

The ED may be a prime location to engage both men and women who are involved in TS in behavioral interventions for substance use and sexual risk reduction.

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By:  Patton R1, Blow FC2, Bohnert AS2, Bonar EE2, Barry KL2, Walton MA2.

• 1The Substance Abuse Research Center, University of Michigan.
• 2Department of Psychiatry, University of Michigan. 
• Psychol Addict Behav. 2014 Jun;28(2):625-30. doi: 10.1037/a0035417.

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Impact of Mental Health and Substance Use Disorders on Emergency Department Visit Outcomes for HIV Patients

INTRODUCTION:

A disproportionate number of individuals with human immunodeficiency virus (HIV) have mental health and substance-use disorders (MHSUDs), and MHSUDs are significantly associated with their emergency department (ED) visits. With an increasing share of older adults among HIV patients, this study investigated the associations of MHSUDs with ED outcomes of HIV patients in four age groups: 21-34, 35-49, 50-64, and 65+ years.

METHODS:

We used the 2012 Nationwide Emergency Department Sample (NEDS) dataset (unweighted n=23,244,819 ED events by patients aged 21+, including 115,656 visits by patients with HIV). Multinomial and binary logistic regression analyses, with "treat-and-release" as the base outcome, were used to examine associations between ED outcomes and MHSUDs among visits that included a HIV diagnosis in each age group.

RESULTS:

• Mood and "other" mental disorders had small effects on ED-to-hospital admissions, as opposed to treat-and-release, in age groups younger than 65+ years, while suicide attempts had medium effects . 
• Cognitive disorders had medium-to-large effects on hospital admissions in all age groups and large effects on death in the 35-49 age groups. 
• Alcohol use disorders (AUDs) had small effects on hospital admission in all age groups. 
• Drug use disorders (DUDs) had small-to-medium effects on hospital admission. AUDs and DUDs were also significantly related to the risk of death, and DUDs had a small effect on the risk of discharge against medical advice in the 35-49 and 50-64 age groups.

CONCLUSION:

The high prevalence of MHSUDs and their significant roles in ED visit outcomes in patients with HIV provide support for integrated care for these patients outside the ED to reduce their ED visits and costly hospital admissions and institutional care that follows, especially for the increasing numbers of older adults with HIV.

Full article at:   http://goo.gl/3tf6pP

By:  Choi BY1, DiNitto DM2, Marti CN2, Choi NG2.

• 1Warren Alpert Medical School at Brown Univeristy and Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island.
• 2The University of Texas at Austin, School of Social Work, Austin, Texas. 
• West J Emerg Med. 2016 Mar;17(2):153-64. doi: 10.5811/westjem.2016.1.28310. Epub 2016 Mar 2.

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Emergency Department Visits for Homelessness or Inadequate Housing in New York City Before and After Hurricane Sandy

Hurricane Sandy struck New York City on October 29, 2012, causing not only a large amount of physical damage, but also straining people's health and disrupting health care services throughout the city. In prior research, we determined that emergency department (ED) visits from the most vulnerable hurricane evacuation flood zones in New York City increased after Hurricane Sandy for several medical diagnoses, but also for the diagnosis of homelessness. 

In the current study, we aimed to further explore this increase in ED visits for homelessness after Hurricane Sandy's landfall. We performed an observational before-and-after study using an all-payer claims database of ED visits in New York City to compare the demographic characteristics, insurance status, geographic distribution, and health conditions of ED patients with a primary or secondary ICD-9 diagnosis of homelessness or inadequate housing in the first week after Hurricane Sandy's landfall versus the baseline weekly average in 2012 prior to Hurricane Sandy. 

We found statistically significant increases in ED visits for diagnosis codes of homelessness or inadequate housing in the week after Hurricane Sandy's landfall. Those accessing the ED for homelessness or inadequate housing were more often elderly and insured by Medicare after versus before the hurricane. 

Secondary diagnoses among those with a primary ED diagnosis of homelessness or inadequate housing also differed after versus before Hurricane Sandy. These observed differences in the demographic, insurance, and co-existing diagnosis profiles of those with an ED diagnosis of homelessness or inadequate housing before and after Hurricane Sandy suggest that a new population cohort-potentially including those who had lost their homes as a result of storm damage-was accessing the ED for homelessness or other housing issues after the hurricane. 

Emergency departments may serve important public health and disaster response roles after a hurricane, particularly for people who are homeless or lack adequate housing. Further, tracking ED visits for homelessness may represent a novel surveillance mechanism to assess post-disaster infrastructure impact and to prepare for future disasters.

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By:  Doran KM1,2, McCormack RP1, Johns EL3, Carr BG4,5, Smith SW1, Goldfrank LR1, Lee DC6,7.

• 1Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA.
• 2Department of Population Health, New York University School of Medicine, New York, NY, USA.
• 3New York City Center for Innovation through Data Intelligence, New York, NY, USA.
• 4Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
• 5Emergency Care Coordination Center, Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC, USA.
• 6Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA. david.lee@nyumc.org.
• 7Department of Population Health, New York University School of Medicine, New York, NY, USA. david.lee@nyumc.org. 
• J Urban Health. 2016 Mar 15.

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Accuracy of Reported Service Use in a Cohort of People Who Are Chronically Homeless & Seriously Mentally Ill

Background

Self-reported service use is an integral feature of interventional research with people who are homeless and mentally ill. The objective of this study was to investigate the accuracy of self-reported involvement with major categories of publicly funded services (health, justice, social welfare) within this sub-population.

Methods

Measures were administered pre-randomization in two randomized controlled trials, using timeline follow back with calendar aids for Health, Social, and Justice Service Use, compared to linked administrative data. Variables examined were: psychiatric admissions (both extended stays of more than 6 months and two or more stays within 5 years); emergency department visits, general hospitalization and jail in the past 6 months; and income assistance in the past 1 month. Participants (n = 433) met criteria for homelessness and a least one mental illness.

Results

Prevalence adjusted and bias adjusted kappa (PABAK) values ranged between moderate and almost perfect for extended psychiatric hospital separations, multiple psychiatric hospitalizations, emergency department visits, jail, and income assistance. Significant differences in under versus over reporting were also found.

Conclusions

People who are homeless and mentally ill reliably reported their overall use of health, justice, and income assistance services. Evidence of under-reporting and over-reporting of certain variables has implications for specific research questions.

Full article at:   http://goo.gl/ROq2xv

By:  Julian M. Somers, Akm Moniruzzaman, Lauren Currie, Stefanie N. Rezansoff, Angela Russolillo, and Milad Parpouchi

Somers Research Group, Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

Julian M. Somers, Email: ac.ufs@sremosj.

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Sexually Transmitted Infection History among Adolescents Presenting to the Emergency Department

BACKGROUND:

Adolescents and young adults account for about half of the annual diagnoses of sexually transmitted infections (STI) in the United States. Screening and treatment for STIs, as well as prevention, are needed in health-care settings to help offset the costs of untreated STIs.

OBJECTIVE:

Our aim was to evaluate the prevalence and correlates of self-reported STI history among adolescents presenting to an emergency department (ED).

METHODS:

Over two and a half years, 4389 youth (aged 14-20 years) presenting to the ED completed screening measures for a randomized controlled trial. About half (56%) reported lifetime sexual intercourse and were included in analyses examining sexual risk behaviors (e.g., inconsistent condom use), and relationships of STI history with demographics (sex, age, race, school enrollment), reason for ED presentation (i.e., medical or injury), and substance use.

RESULTS:

Among sexually active youth, 10% reported that a medical professional had ever told them they had an STI (212 females, 35 males). Using logistic regression, female sex, older age, non-Caucasian race, not being enrolled in school, medically related ED chief complaint, and inconsistent condom use were associated with increased odds of self-reported STI history.

CONCLUSIONS:

One in 10 sexually active youth in the ED reported a prior diagnosed STI. Previous STI was significantly higher among females than males. ED providers inquiring about inconsistent condom use and previous STI among male and female adolescents may be one strategy to focus biological testing resources and improve screening for current STI.

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By:  Bonar EE1, Walton MA2, Caldwell MT3, Whiteside LK4, Barry KL5, Cunningham RM6.

• 1Department of Psychiatry, Addiction Research Center, University of Michigan, Ann Arbor, Michigan.
• 2Department of Psychiatry, Addiction Research Center, University of Michigan, Ann Arbor, Michigan; Injury Center, University of Michigan, Ann Arbor, Michigan.
• 3Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan.
• 4Division of Emergency Medicine, University of Washington, Seattle, Washington.
• 5Department of Veterans Affairs National Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, Michigan; Department of Psychiatry, Mental Health Services Outcomes and Translation Section, University of Michigan, Ann Arbor, Michigan.
• 6Injury Center, University of Michigan, Ann Arbor, Michigan; Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; School of Public Health, University of Michigan, Ann Arbor, Michigan. 
• J Emerg Med. 2015 Nov;49(5):613-22. doi: 10.1016/j.jemermed.2015.02.017. Epub 2015 May 4.

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mHealth Tool for Alcohol Use Disorders among Latinos in Emergency Department

Latino drinkers experience a disparate number of negative health and social consequences. Emergency Department Alcohol Screening Brief Intervention and Referral to Treatment (ED-SBIRT) is viable and effective at reducing harmful and hazardous drinking. However, barriers (e.g. readily available language translators, provider time burden, resources) to broad implementation remain and account for a major lag in adherence to national guidelines. We describe our approach to the design of a patient-centered bilingual Web-based mobile health ED-SBIRT App that could be integrated into a clinically complex ED environment and used regularly to provide ED-SBIRT for Spanish speaking patients.

Below:  AB-CASI Language Selection Screen

Below:  AB-CASI Frequency of Drinks Screen

Below:  Architecture of ED-SBIRT Mobile App Bilingual Text-to-Speech Generation

Below:  AB-CASI Ruler Screen

Full article at:   http://goo.gl/3r2GIa

By:  Fuad Abujarad and Federico E. Vaca

Department of Emergency Medicine Yale University, School of Medicine New Haven, Connecticut

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10-Year Risks of Death and Emergency Re-admission in Adolescents Hospitalised with Violent, Drug- or Alcohol-Related, or Self-Inflicted Injury

Background

Hospitalisation for adversity-related injury (violent, drug/alcohol-related, or self-inflicted injury) has been described as a “teachable moment”, when intervention may reduce risks of further harm. Which adolescents are likely to benefit most from intervention strongly depends on their long-term risks of harm. We compared 10-y risks of mortality and re-admission after adversity-related injury with risks after accident-related injury.

Methods and Findings

We analysed National Health Service admissions data for England (1 April 1997–31 March 2012) for 10–19 y olds with emergency admissions for adversity-related injury (violent, drug/alcohol-related, or self-inflicted injury; n = 333,009) or for accident-related injury (n = 649,818). We used Kaplan–Meier estimates and Cox regression to estimate and compare 10-y post-discharge risks of death and emergency re-admission. Among adolescents discharged after adversity-related injury, one in 137 girls and one in 64 boys died within 10 y, and 54.2% of girls and 40.5% of boys had an emergency re-admission, with rates being highest for 18–19 y olds. Risks of death were higher than in adolescents discharged after accident-related injury (girls: age-adjusted hazard ratio 1.61, 95% CI 1.43–1.82; boys: 2.13, 95% CI 1.98–2.29), as were risks of re-admission (girls: 1.76, 95% CI 1.74–1.79; boys: 1.41, 95% CI 1.39–1.43). Risks of death and re-admission were increased after all combinations of violent, drug/alcohol-related, and self-inflicted injury, but particularly after any drug/alcohol-related or self-inflicted injury (i.e., with/without violent injury), for which age-adjusted hazard ratios for death in boys ranged from 1.67 to 5.35, compared with 1.25 following violent injury alone (girls: 1.09 to 3.25, compared with 1.27). The main limitation of the study was under-recording of adversity-related injuries and misclassification of these cases as accident-related injuries. This misclassification would attenuate the relative risks of death and re-admission for adversity-related compared with accident-related injury.

Conclusions

Adolescents discharged after an admission for violent, drug/alcohol-related, or self-inflicted injury have increased risks of subsequent harm up to a decade later. Introduction of preventive strategies for reducing subsequent harm after admission should be considered for all types of adversity-related injury, particularly for older adolescents.

Below:  Cumulative risk of death in girls, by age group

Below:  Cumulative risk of death in boys, by age group

Full article at:  http://goo.gl/9aTBUR

By:   

Annie Herbert, Ruth Gilbert, Arturo González-Izquierdo, Leah Li

Population, Policy & Practice Programme, Institute of Child Health, University College London, London, United Kingdom

Annie Herbert, Ruth Gilbert, Arturo González-Izquierdo

Farr Institute of Health Informatics Research, Department of Epidemiology and Public Health, University College London, London, United Kingdom

Alexandra Pitman

Division of Psychiatry, University College London, London, United Kingdom

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Increased HIV Testing among Hospitalized Patients Who Declined Testing in the Emergency Department

Health-care systems have serial encounters with many of the same patients across care settings; however, few studies have examined the role of reoffering HIV testing after a patient declines. 

We assessed whether an intervention to increase HIV testing among hospitalized patients was associated with increased testing among those who declined a test while in the Emergency Department (ED). We studied 8-week periods pre- and post-implementation of an electronic medical record (EMR)-based intervention to increase HIV testing among hospitalized patients. 

We included all patients 21-64 years old who had no prior HIV test, declined HIV testing in the ED, and were subsequently hospitalized. We used logistic regression to test for an association between time of hospital admission (pre- vs. post-intervention) and whether an HIV test was performed prior to discharge. Pre- and post-implementation, 220 and 218 patients who declined HIV testing in the ED were hospitalized, respectively. There were no significant demographic or clinical differences among patients pre- and post-implementation. Pre- and post-implementation, the median proportion of patients tested weekly was 6.7% (IQR 6.5%, 10.0%) and 41.4% (IQR 33.3%, 41.9%), respectively (aOR 6.2: 95%CI: 3.6, 10.6). HIV testing increased among hospitalized patients who declined a test in the ED after implementation of an EMR-based intervention. 

Almost half of the patients who declined testing in the ED ultimately underwent testing after it was reoffered during hospitalization, suggesting that the decision to undergo HIV testing is a dynamic process. 

Leveraging EMR resources may be an effective tool for expanding HIV testing, and testing should be reoffered to patients who previously declined.

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By:   Felsen UR1, Cunningham CO2, Zingman BS1.

• 1 Division of Infectious Diseases , Albert Einstein College of Medicine/Montefiore Medical Center , Bronx , NY , USA.
• 2 Division of General Internal Medicine , Albert Einstein College of Medicine/Montefiore Medical Center , Bronx , NY , USA. 

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Debunking Three Rape Myths

BACKGROUND:

Stereotypes and prejudicial misconceptions are prevalent regarding sexual assaults and victims' responses. These are collectively referred to as rape myths. This study examines three rape myths purporting that sexual assault victims (1) immediately report the crime, (2) experience severe physical and/or anogenital injuries, and (3) forcefully resist their assailant.

STUDY DESIGN:

This is a cross-sectional descriptive study examining presence of physical or anogenital injury, level of physical resistance during a sexual assault, and time to sexual assault report. Study subjects were female sexual assault victims examined by a sexual assault nurse examiner at Regions Hospital in St. Paul, Minnesota, in 2011 and 2012.

RESULTS:

Sexual assault nurse examiner reports for 317 subjects met the inclusion criteria and were reviewed. Twelve (4%) victims experienced physical injury requiring medical intervention. Thirty-four (11%) sustained anogenital injuries requiring medical intervention. Overall, 253 (81%) victims did not actively resist at some point during the assault, with 178 (57%) victims never actively resisting. Nearly half (129, 43%) did not appear in the emergency department for 12 or more hours from the time of the assault.

CONCLUSION:

Women who seek emergency department assistance after a sexual assault take a variable amount of time to present to the emergency department, rarely experience moderate or severe physical or anogenital injury, and commonly do not exert strong physical resistance against their attacker during at least part of the assault.

Below:  Delay from the end of assault to ED presentation

Below:  Patient and Assault Characteristics

Below:  Univariate Predictors of Three Key Outcomes

Below:  Frequency of Any Injury During the Assault, Shown Separately by Level of Resistance

Full article at:   http://goo.gl/f1lP0Z

By:   Carr M1, Thomas AJ, Atwood D, Muhar A, Jarvis K, Wewerka SS.

• 1Author Affiliations: 1Department of Emergency Medicine, Regions Hospital; 2Health Partners Institute for Education and Research; 3Medical College of Wisconsin; 4University of Minnesota Medical School; 5Sexual Assault Nurse Examiner Program, Regions Hospital; and 6Critical Care Research Center, Regions Hospital. 

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Who Shot Ya? How Emergency Departments Can Collect Reliable Police Shooting Data

This paper examines an alternative solution for collecting reliable police shooting data. 

One alternative is the collection of police shooting data from hospital trauma units, specifically hospital-based violence intervention programs. These programs are situated in Level I trauma units in many major cities in USA. 

While the intent of these programs is to reduce the risk factors associated with trauma recidivism among victims of violent injury, they also collect reliable data on the number of individuals treated for gunshot wounds. While most trauma units do a great job collecting data on mode of injury, many do not collect data on the circumstances surrounding the injury, particularly police-involved shootings. 

Research protocol on firearm-related injury conducted in emergency departments typically does not allow researchers to interview victims of violent injury who are under arrest. Most victims of nonfatal police-involved shootings are under arrest at the time they are treated by the ED for their injury. Research protocol on victims of violent injury often excludes individuals under arrest; they fall under the exclusion criteria when recruiting potential participants for research on violence. Researchers working in hospital emergency departments are prohibited from recruited individuals under arrests. The trauma staff, particularly ED physicians and nurses, are in a strategic position to collect this kind of data. 

Thus, this paper examines how trauma units can serve as an alternative in the reliable collection of police shooting data.

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By:   Richardson JB Jr1,2.

• 1Department of African-American Studies, College Park, MD, USA. jrichar5@umd.edu.
• 2Violence Intervention Research Project, Prince George's Hospital Trauma Center, Cheverly, MD, USA. jrichar5@umd.edu. 

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Do Drug Seizures Predict Drug-Related Emergency Department Presentations or Arrests for Drug Use & Possession?

BACKGROUND:

Direct evidence of the effect of drug seizures on drug use and drug-related harm is fairly sparse. The aim of this study was to see whether seizures of heroin, cocaine and ATS predict the number of people arrested for use and possession of these drugs and the number overdosing on them.

METHOD:

We examined the effect of seizure frequency and seizure weight on arrests for drug use and possession and on the frequency of drug overdose with auto regressive distributed lag (ARDL) models. Granger causality tests were used to test for simultaneity.

RESULTS:

Over the short term (i.e. up to 4 months), increases in the intensity of high-level drug law enforcement (as measured by seizure weight and frequency) directed at ATS, cocaine and heroin did not appear to have any suppression effect on emergency department (ED) presentations relating to ATS, cocaine and heroin, or on arrests for use and/or possession of these drugs. A significant negative contemporaneous relationship was found between the heroin seizure weight and arrests for use and/or possession of heroin. However no evidence emerged of a contemporaneous or lagged relationship between heroin seizures and heroin ED presentations.

CONCLUSION:

The balance of evidence suggests that, in the Australian context, increases in the monthly seizure frequency and quantity of ATS, cocaine and heroin are signals of increased rather than reduced supply.

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By:  Wan WY1, Weatherburn D2, Wardlaw G3, Sarafidis V4, Sara G5.

• 1NSW Bureau of Crime Statistics and Research, Sydney, Australia.
• 2NSW Bureau of Crime Statistics and Research, Sydney, Australia. Electronic address: Don_J_Weatherburn@agd.nsw.gov.au.
• 3National Security College, Australian National University, Canberra, Australia.
• 4Department of Econometrics and Business Statistics, Monash University, Caulfield, Australia.
• 5NSW Ministry of Health, Sydney, Australia; Discipline of Psychiatry, Sydney Medical School University of Sydney, Australia. 

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