Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

[West J Emerg Med. 2012;13(3):215-216.]

[West J Emerg Med. 2012;13(3):217–219.]

Objective: This study analyzed predictors of post-traumatic stress disorder (PTSD) in civilian trauma victims to assess how peritraumatic dissociation (PD) relates to PTSD symptom development. We examined PD and PTSD symptoms from a prior trauma simultaneously to better understand the extent towhich past and current reactions to a trauma can predict the development of PTSD for a current trauma.

Methods: Participants (N¼48) were recruited from the emergency department (ED) of a large, southeastern hospital and assessed immediately after a trauma and again at 4 weeks and 12 weekspost-trauma. We used both self-report and interviewer-based questionnaires to assess PD and PTSD symptoms for prior and current trauma.

Results: A hierarchical linear regression revealed that at 4-week follow up, when controlling for several demographic variables and trauma type, a model including both PD and PTSD symptoms from a prior trauma significantly predicted PTSD outcome (F(47)¼3.70, p¼0.00), with PD and prior PTSD symptoms significantly contributing 17% and 9% of variance respectively. At 12 weeks, PTSD symptoms from prior trauma (b¼0.094, p¼0.538) and PD (b¼0.017, p¼0.909) did not account for a significant proportion of the variance in PTSD for the enrolling trauma.

Conclusion: Prior and current reactions to trauma are both important factors in predicting the development of PTSD symptoms to a current trauma. The more immediate measurement of PD during presentation to the ED may explain the strength of its relationship to PTSD symptom development.Furthermore, our findings support the use of PTSD symptoms of a past trauma, as opposed to trauma frequency, as a predictor of PTSD from a subsequent trauma. Methodological limitations and future directions are discussed. [West J Emerg Med. 2012;13(3):220–224.]

Introduction: Although national guidelines have been published for the management of critically injured traumatic cardiopulmonary arrest (TCPA) patients, many hospital systems have not implemented in-hospital triage guidelines. The objective of this study was to determine if hospital resources could be preserved by implementation of an in-hospital tiered triage system for patients in TCPA with prolonged resuscitation who would likely be declared dead on arrival (DOA).

Method: We conducted a retrospective analysis of 4,618 severely injured patients, admitted to our Level I trauma center from December 2000 to December 2008 for evaluation. All of the identified patients had sustained life-threatening penetrating and blunt injuries with pre-hospital TCPA. Patients who received cardiopulmonary resuscitation (CPR) for 10 minutes were assessed for survival rate, neurologic outcome, and charge-for-activation (COA) for our hospital trauma system.

Results: We evaluated 4,618 charts, which consisted of patients seen by the MSM trauma service from December 2001 through December 2008. We identified 140 patients with severe, life-threatening traumatic injuries,who sustained pre-hospitalTCPArequiring prolongedCPRin the field andwere brought to the emergency department (ED).Group I was comprised of 108 patients sustaining TCPA (53 blunt, 55penetrating), who died after receiving, 45 minutes of ACLS after arrival. Group II, which consisted of 32 patients (25 blunt, 7 penetrating), had resuscitative efforts in the EDlasting.45 minutes, but all ultimately died prior to discharge. Estimated hospital charge-for-activation for Group I was approximately $540,000, based on standard charges of $5000 per full-scale trauma system activation (TSA).

Conclusion: Full-scale trauma system activation for patients sustaining greater than 10 minutes of prehospital TCPA in the field is futile and economically depleting. [West J Emerg Med. 2012;13(3):225–229.]

Introduction: Traumatic brain injury (TBI) can be complicated among older adults due to age-related frailty, a greater prevalence of chronic conditions and the use of anticoagulants. We conducted this study using the latest available, nationally-representative emergency department (ED) data to characterize visits for TBI among older adults.

Methods: We used the 2006-2008 National Hospital Ambulatory Medical Care – Emergency Department (NHAMCS-ED) data to examine ED visits for TBI among older adults. Population-level estimates of triage immediacy, receipt of a head computed tomography (CT) and/or head magnetic resonance imaging (MRI), and hospital admission by type were used to characterize 1,561 sample visits, stratified by age <65 and ≥65 years of age.

Results: Of ED visits made by persons ≥65 years of age, 29.1% required attention from a physician within 15 minutes of arrival; 82.1% required a head CT, and 20.9% required hospitalization. Persons≥65 years of age were 3 times more likely to receive a head CT or MRI compared to younger patients presenting with TBI (adjusted odds ratio [aOR] 3.2; 95% confidence interval [CI], 1.8-5.8), and were 4 times more likely to be admitted to an intensive care unit, step-down unit, or surgery (aOR 4.1; 95% CI 2.1-8.0) compared to younger patients presenting with TBI, while controlling for sex and race.

Conclusion: Results demonstrate increased emergent service delivery for older persons presenting with TBI. As the United States population ages and continues to grow, TBI will become an even more important public health issue that will place a greater demand on the healthcare system. [West J Emerg Med. 2012;13(3):289-293.]

Introduction: Poisoning, specifically unintentional poisoning, is a major public health problem in the United States (U.S.). Published literature that presents epidemiology of all forms of poisoning mortalities (i.e., unintentional, suicide, homicide) together is limited. This report presents data and summarizes the evidence on poisoning mortality by demographic and geographic characteristics to describe the burden of poisoning mortality and the differences among sub-populations in the U.S. for a 5-year period.

Methods: Using mortality data from the Center for Disease Control and Prevention’s Web-based Injury Statistics Query and Reporting System, we presented the age-specific and age-adjusted unintentional and intentional (suicide, homicide) poisoning mortality rates by sex, age, race, and state of residence for the most recent years (2003–2007) of available data. Annual percentage changes in deaths and rates were calculated, and linear regression using natural log were used for time-trend analysis.

Results: There were 121,367 (rate¼8.18 per 100,000) unintentional poisoning deaths. Overall, the unintentional poisoning mortality rate increased by 46.9%, from 6.7 per 100,000 in 2003 to 9.8 per100.000 in 2007, with the highest mortality rate among those aged 40–59 (rate¼15.36), males(rate¼11.02) and whites (rate¼8.68). New Mexico (rate¼18.2) had the highest rate. Unintentional poisoning mortality rate increased significantly among both sexes, and all racial groups except blacks (p,0.05 time-related trend for rate). Among a total of 29,469 (rate¼1.97) suicidal poisoning deaths, the rate increased by 9.9%, from 1.9 per 100,000 in 2003 to 2.1 per 100,000 in 2007, with the highest rate among those aged 40–59 (rate¼3.92), males (rate¼2.20) and whites (rate¼2.24). Nevada(rate¼3.9) had the highest rate. Mortality rate increased significantly among females and whites only (p,0.05 time-related trend for rate). There were 463 (rate¼0.03) homicidal poisoning deaths and the rate remained the same during 2003–2007. The highest rates were among aged 0–19 (rate¼0.05), males (rate¼0.04) and blacks (rate¼0.06).

Conclusion: Prevention efforts for poisoning mortalities, especially unintentional poisoning, should be developed, implemented and strengthened. Differences exist in poisoning mortality by age, sex, location, and these findings underscore the urgency of addressing this public health burden as this epidemic continues to grow in the U.S. [West J Emerg Med. 2012;13(3):230–238.]

Introduction: Self-exposure is a leading method for suicide both in the United States and worldwide and thus is a major preventable public health issue. Surrogate decision makers are tasked with making medical decisions for the patient while keeping the patient’s wishes in mind. Decisions related to code status become more complicated when the patient’s situation is the result of a suicidal act. The objectives were to 1) determine how frequently Do Not Resuscitate orders (DNR orders) are placed for the intentionally self-exposed (ISE) patient using the Regional Poison Control Center (RPCC) data, and 2) identify if DNR orders in intentionally self-exposed patients were placed before or afterdevelopment of poor prognostic signs.

Methods: We analyzed all exposure-related deaths reported to the RPCC from January 1, 2000 to December 31, 2010. We reviewed data for the following: exposure intent, exposure substance, outcome, age, code status, date of DNR/withdrawal of care order, previous suicide attempts, and poor prognostic signs.

Results: Of the 476 total deaths, nearly half were the result of an intentional self-exposure (n= 235; 49.4%). Most deaths, when code status was reported, had advanced cardiac life support, or “fullcodes” (n=131; 55.6%). Of the total deaths with a DNR or withdrawal of care order (n=104), over half were from an ISE (n=55; 52.9%). A higher percentage of the ISEs had a DNR order/withdrawal of careorder; however, it was not a statistically significant difference OR 1.23 (95% CI 0.64, 2.37). Regardless of intent, patients treated as full codes were on average 19.5 years younger than the DNR orders group. Only 2 DNR orders were placed prior to development of poor prognostic signs. Unintentional self-exposures consumed a mean of 1.4 substances (range 1 to 4). ISEs consumed a mean of 2.3 substances (range 1 to 19).

Conclusion: People are often asked to make life-and-death decisions for a loved one. The nature of the exposure can complicate the issue if the exposure has an antidote or is known to have a limited effect. Further study is needed to assess the extent of these cases and to identify optimal management guidelines or policy to aid both the medical teams caring for these patients and the surrogate decision makers. [West J Emerg Med. 2012;13(3):294-297.]

Introduction: To investigate relationships between ambient temperatures and violent crimes to determine whether those relationships are consistent across different crime categories and whether they are best described as increasing linear functions, or as curvilinear functions that decrease beyond some temperature threshold. A secondary objective was to consider the implications of the observed relationships for injuries and deaths from violent crimes in the context of a warming climate. To address these questions, we examined the relationship between daily ambient temperatures and daily incidents of violent crime in Dallas, Texas from 1993–1999.

Methods: We analyzed the relationships between daily fluctuations in ambient temperature, other meteorological and temporal variables, and rates of daily violent crime using time series piece-wise regression and plots of daily data. Violent crimes, including aggravated assault, homicide, and sexualassault, were analyzed.

Results: We found that daily mean ambient temperature is related in a curvilinear fashion to daily rates of violent crime with a positive and increasing relationship between temperature and aggravated crime that moderates beyond temperatures of 80 F and then turns negative beyond 90 F.

Conclusion: While some have characterized the relationship between temperature and violent crime as a continually increasing linear function, leaving open the possibility that aggravated crime will increase in a warmer climate, we conclude that the relationship in Dallas is not linear, but moderatesand turns negative at high ambient temperatures. We posit that higher temperatures may encourage people to seek shelter in cooler indoor spaces, and that street crime and other crimes of opportunity are subsequently decreased. This finding suggests that the higher ambient temperatures expected with climate change may result in marginal shifts in violent crime in the short term, but are not likely to be accompanied by markedly higher rates of violent crime and associated increased incidence of injuryand death. Additional studies are indicated, across cities at varying latitudes that experience a range of daily ambient temperatures. [West J Emerg Med. 2012;13(3):239–246.]

Introduction: This research sought to extend knowledge about bystanders in bullying situations with a focus on the motivations that lead them to different responses. The 2 primary goals of this study were to investigate the reasons for children’s decisions to help or not to help a victim when witnessing bullying, and to generate a grounded theory (or conceptual framework) of bystander motivation in bullying situations.

Methods: Thirty students ranging in age from 9 to 15 years (M=11.9; SD=1.7) from an elementary and middle school in the southeastern United States participated in this study. Open- ended, semistructured interviews were used, and sessions ranged from 30 to 45 minutes. We conducted qualitative methodology and analyses to gain an in-depth understanding of children’s perspectives and concerns when witnessing bullying.

Results: A key finding was a conceptual framework of bystander motivation to intervene in bullying situations suggesting that deciding whether to help or not help the victim in a bullying situation depends on how bystanders define and evaluate the situation, the social context, and their own agency. Qualitative analysis revealed 5 themes related to bystander motives and included: interpretation of harm in the bullying situation, emotional reactions, social evaluating, moral evaluating, and intervention self-efficacy.

Conclusion: Given the themes that emerged surrounding bystanders’ motives to intervene or abstain from intervening, respondents reported 3 key elements that need to be confirmed in future research and that may have implications for future work on bullying prevention. These included: first, the potential importance of clear communication to children that adults expect bystanders to intervene when witnessing bullying; second, the potential of direct education about how bystanders can interveneto increase children’s self-efficacy as defenders of those who are victims of bullying; and third, the assumption that it may be effective to encourage children’s belief that bullying is morally wrong. [West J Emerg Med. 2012;13(3):247–252.]

Introduction: Violence among youth is a major public health issue globally. Despite these concerns, youth violence surveillance and prevention research are either scarce or non-existent, particularly in developing regions, such as sub-Saharan Africa. The purpose of this study is to quantitatively determine the prevalence of violence involving weapons in a convenience sample of service-seeking youth in Kampala. Moreover, the study will seek to determine the overlap between violence victimization and perpetration among these youth and the potentially shared risk factors for these experiences.

Methods: We conducted this study of youth in May and June of 2011 to quantify and describe high-risk behaviors and exposures in a convenience sample (N¼457) of urban youth, 14–24 years of age, living on the streets or in the slums and who were participating in a Uganda Youth Development Link drop-incenter for disadvantaged street youth. We computed bivariate and multivariate logistic regression analyses to determine associations between psychosocial factors and violence victimization and perpetration.

Results: The overall prevalence of reporting violence victimization involving a weapon was 36%, and violence perpetration with a weapon was 19%. In terms of the overlap between victimization and perpetration, 16.6% of youth (11.6% of boys and 24.1% of girls) reported both. In multivariate analyses, parental neglect due to alcohol use (Adj.OR¼2.28;95%CI: 1.12—4.62) and sadness (Adj.OR=4.36 ;95%CI: 1.81—10.53) were the statistically significant correlates of victimization only. Reportinghunger (Adj.OR=2.87 ;95%CI:1.30—6.33), any drunkenness (Adj.OR=2.35 ;95%CI:1.12—4.92) and any drug use (Adj.OR=3.02 ;95%CI:1.16—7.82) were significantly associated with both perpetration and victimization.

Conclusion: The findings underscore the differential experiences associated with victimization and perpetration of violence involving weapons among these vulnerable youth. In particular, reporting hunger, drunkenness and drug use were specifically associated with victimization and perpetration. These are all modifiable risk factors that can be prevented. It is clear that these vulnerable youth are in need of additional services and guidance to ameliorate their adverse childhood experiences, current health risk behaviors and disadvantaged living context. [West J Emerg Med. 2012;13(3):253–259.]

Introduction: Recent research suggests that men who have sex with men (MSM) experience intimate partner violence (IPV) at significantly higher rates than heterosexual men. Few studies, however, have investigated implications of heterosexist social pressures – namely, homophobic discrimination, internalized homophobia, and heterosexism– on risk for IPV among MSM, and no previous studies have examined cross-national variations in the relationship between IPV and social pressure. This paperexamines reporting of IPV and associations with social pressure among a sample of internet-recruited MSM in the United States (U.S.), Canada, Australia, the United Kingdom, South Africa, and Brazil.

Methods: We recruited internet-using MSM from 6 countries through selective banner advertisements placed on Facebook. Eligibility criteria were men age over 18 reporting sex with a man in the past year. Of the 2,771 eligible respondents, 2,368 had complete data and were included in the analysis. Threeoutcomes were examined: reporting recent experience of physical violence, sexual violence, and recent perpetration of physical violence. The analysis focused on associations between reporting of IPV and experiences of homophobic discrimination, internalized homophobia, and heteronormativity.

Results: Reporting of experiencing physical IPV ranged from 5.75% in the U.S. to 11.75% in South Africa, while experiencing sexual violence was less commonly reported and ranged from 2.54% in Australia to 4.52% in the U.S. Perpetration of physical violence ranged from 2.47% in the U.S. to 5.76% in South Africa. Experiences of homophobic discrimination, internalized homophobia, and heteronormativity were found to increase odds of reporting IPV in all countries.

Conclusion: There has been little data on IPV among MSM, particularly MSM living in low- and middleincome countries. Despite the lack of consensus in demographic correlates of violence reporting, heterosexist social pressures were found to significantly increase odds of reporting IPV in all countries.These findings show the universality of violence reporting amongMSMacross countries, and highlight the unique role of heteronormativity asa risk factor for violence reporting among MSM. The results demonstrate that using internet-based surveys to reachMSMis feasible for certain areas, although modified effortsmay be required to reach diverse samples of MSM. [West J Emerg Med. 2012;13(3):260–271.]

Introduction: The purposes of this study were to assess the extent to which latent trajectories of female intimate partner violence (IPV) victimization exist; and, if so, use negative childhood experiences to predict trajectory membership.

Methods: We collected data from 1,575 women at 5 time-points regarding experiences during adolescence and their 4 years of college. We used latent class growth analysis to fit a series of personcentered, longitudinal models ranging from 1 to 5 trajectories. Once the best-fitting model was selected, we used negative childhood experience variables—sexual abuse, physical abuse, and witnessing domestic violence—to predict most-likely trajectory membership via multinomial logistic regression.

Results: A 5-trajectory model best fit the data both statistically and in terms of interpretability. The trajectories across time were interpreted as low or no IPV, low to moderate IPV, moderate to low IPV, high to moderate IPV, and high and increasing IPV, respectively. Negative childhood experiences differentiated trajectory membership, somewhat, with childhood sexual abuse as a consistent predictor of membership in elevated IPV trajectories.

Conclusion: Our analyses show how IPV risk changes over time and in different ways. These differential patterns of IPV suggest the need for prevention strategies tailored for women that consider victimization experiences in childhood and early adulthood. [West J Emerg Med. 2012;13(3):272–277.]

Introduction: We assessed the correlation between intimate partner violence (IPV) and health behaviors, including seat belt use, smoke alarm in home, handgun access, body mass index, diet, and exercise. We hypothesized that IPV victims would be less likely to have healthy behaviors as compared to women with similar demographics.

Methods: All adult female patients who presented to 3 Atlanta-area emergency department waiting rooms on weekdays from 11AM to 7PM were asked to participate in a computer-based survey by trained research assistants. The Universal Violence Prevention Screen was used for IPV identification. The survey also assessed seatbelt use, smoke alarm presence, handgun access, height, weight, exercise, and diet. We used chi-square tests of association, odds ratios, and independent t-tests tomeasure associations between variables.

Results: Participants ranged from 18 to 68 years, with a mean of 38 years. Out of 1,452 respondents, 155 patients self-identified as white (10.7%), and 1,218 as black (83.9%); 153 out of 832 women who were in a relationship in the prior year (18.4%) screened positive for IPV. We found significant relationships between IPV and not wearing a seatbelt (p,0.01), handgun access (p,0.01), and eating unhealthy foods (p,0.01).

Conclusion: Women experiencing IPV are more likely to exhibit risky health behaviors than women who are not IPV victims. [West J Emerg Med. 2012;13(3):278–282.]

Introduction: The purpose of this study was to examine racial/ethnic disparities in being forced to have sexual intercourse against one’s will, and the effect of substance use on these disparities.

Methods: We analyzed data from adolescent women participating in the Youth Risk Behavior Survey. Bivariate associations and logistic regression models were assessed to examine associations among race/ethnicity, forced sex, and substance use behaviors.

Results: Being forced to have intercourse against one’s will and substance use behaviors differed by race/ethnicity. African Americans had the highest prevalence of having been forced to have sexual intercourse (11.2%). Hispanic adolescent women were the most likely to drink (76.1%), Caucasians to binge drink (28.2%), and African Americans to use drugs (44.3%). When forced sexual intercourse was regressed onto both race/ethnicity and substance use behaviors, only substance use behaviors were significantly associated with forced sexual intercourse.

Conclusion: Differences in substance use behaviors account for the racial/ethnic differences in the likelihood of forced sexual intercourse. Future studies should explore the cultural and other roots of the racial/ethnic differences in substance use behavior as a step toward developing targeted interventions to prevent unwanted sexual experiences. [West J Emerg Med. 2012;13(3):283–288.]

Intimate Partner Violence (IPV) is a major public health issue occurring in the United States and globally. While little is known in general about IPV, understanding about the prevalence of physical IPV among gay men is even more obscure. There is a clear disparity in violence research attention focused on this vulnerable segment of society. This cross-sectional survey study was conducted to examine the feasibility of enrolling 100 gay men from Atlanta into an IPV survey study. The survey was administered via Facebook. Ninety-nine usable surveys were collected. Chi-square tests reveal that minority ethnic status, illicit drug use, and non-disclosed orientation status were all significantly

associated with positive IPV reports--in terms of both victimization as well as perpetration. Overall, the majority of the study sample indicated that they believe IPV is a health problem in the Atlanta gay community. These findings bear importance for the Atlanta gay community and public health professionals who must address this nearly invisible yet increasing public health issue. [West J Emerg Med.2012;13(3):298-304.]

President's Message August 2012