Faculty Bibliography

Background: Mild traumatic brain injuries are frequently evaluated in EDs. Standardized concussion surveillance tools such as the SCAT 3 have been proposed. Developed as a post-injury tool for athletes, SCAT3 is routinely used in pre-injury, baseline assessment. Population-based normative data can aid in interpretation of individual variability or when baseline data are unavailable. To date, all SCAT3 data have been collected in the athlete population with an absence of data on non-athlete (N-A) controls or acutely injured nonathletes. Objectives: We investigate SCAT3 subcomponents in N-A healthy controls, corpus (non head-injured) trauma, and acutely head-injured patients presenting to the ED to derive reference values for novel populations. We hypothesize that trauma patients with suspected head injury will have worse SCAT3 metrics than uninjured controls. Methods: Target groups were extracted from a database of prospectively recruited patients. SCAT3/SAC (Standardized Assessment of Concussion) was administered at time of ED presentation or recruitment. Multi-sample comparisons were evaluated by the Kruskal- Wallis test; pairwise comparisons were analyzed by the Steel-Dwass procedure. Results: A comparison of SCAT3 subcomponents by patient group is seen in Table 732a. One hundred eleven N-A healthy controls, 121 bodily trauma not warranting head CT in ED, 242 head trauma with negative head CT findings, and 67 head trauma patients with positive head CT were evaluated. Control group comparison seen in Table 732b. In number of symptoms, symptom severity score, and SAC, there was a significant difference between control, corpus and - CT/+CT groups. In immediate memory and Balance Error Scoring System (BESS), there was a significant difference between control, corpus, and -CT/+CT, with corpus statistically similar to -CT/ +CT. In concentration, there was a significant difference between control, corpus, and -CT/+CT, with corpus similar to -CT. In orientation, there was a significant difference between control/corpus and -CT/+CT. Conclusion: In healthy, N-A controls, all SCAT3 values were significantly different from all trauma groups'. In -CT/+CT groups, all SCAT3 values were similar to each other. A graded effect was seen from control to corpus to head trauma. Diagnostic ranges of SCAT3 subcomponents vary in the N-A and bodily trauma population. (Table presented)

Background: Certain vulnerable patient groups including the homeless and those with Medicaid insurance are disproportionately represented among ED patients, yet little is known about ED patients' social determinants of health (SDOH). Objectives: This study seeks to quantify the presence of certain SDOH in ED patients. Methods: Using questions from previously validated or widelyused questionnaires, we conducted a cross-sectional survey of a random sample of patients presenting to an urban academic ED. Patients were excluded if they were physically or mentally unfit to participate, were intoxicated, were under police custody, or had already completed the study. Surveys were administered by trained research assistants (RAs) from June-August 2014 seven days a week from 8 am-11 pm and during eight 12 am-8 am shifts. RAs used a random number generator and patient whiteboard displays to select patients to approach. Survey responses were entered by RAs directly into a secure iPad survey platform. Multiple imputation was used for missing data. Results: 1,463 patients were assessed for eligibility, 592 were ineligible, and 246 of those eligible refused to participate, yielding 625 total participants. There were no statistically significant differences in gender or age between those who chose to participate and those who refused. 58.1% of participants were male, 39.8% were Hispanic, 25.9% were black, and 27.2% were white. The most common insurance status was uninsured (28.1%), followed by Medicaid (26.7%). 13.8% of patients were currently living in a homeless shelter or on the streets and 30.5% had been homeless at some point in their lives. In addition, 25.4% of patients reported concern about becoming homeless in the next 2 months and 9.1% had been evicted from their home in the past year. 42.0% of patients reported difficulty meeting essential expenses, 35.9% were worried about running out of food, and 27.7% had not seen a doctor or taken medications (24.5%) because of money concerns. Conclusion: Our survey found high rates of homelessness and other SDOH in ED patients and demonstrates the importance of further research on ED patients' SDOH. Addressing patients' SDOH will become increasingly important under new health care payment models that demand greater accountability for population health

Background: The delivery of palliative care is not standard of care in most EDs. Preliminary data suggest that early palliative care consultation can decrease hospital length of stay and costs for select patients with advanced illness, and may extend life. Objectives: To compare quality of life, health care utilization, and survival for ED patients with advanced cancer randomized to EDinitiated palliative care consultation versus care as usual. Methods: DESI

BACKGROUND: Treating systolic blood pressure (BP) of 150 mmHg with multiple medications prevents cardiovascular events and death. However, modest antihypertensive medication use is associated with an increase in fall injury risk. It is unclear whether the harms outweigh the benefits, and whether the net effects vary by degree of BP control. We aimed to quantify the net effect of increasingly aggressive hypertension control (AHC) on cardiovascular benefit versus fall-related harm in a nationally-representative sample. METHODS: Longitudinal study of 5518 participants of the Health and Retirement Study (HRS) aged 65 or older with self-reported hypertension and taking BP medications, and who had BP measured at baseline by an enhanced HRS exam in 2008 or 2010 (two randomly-assigned, mutually exclusive cohorts). The sample was categorized by increasing AHC: (1) untreated SBP >160 mmHg, (2) poorly controlled and treated SBP >160 mmHg, (3) adequate control, defined as treated SBP 121-159 mmHg or untreated SBP 140-159 mmHg, and (4) overly aggressive SBP treated to <120 mmHg. The 120 and 160mmHg cutoffs ensured that the over-and under-control groups were truly different from 140 mmHg. We determined the effect of AHC over a 2-year follow-up (2008-10 or 2010-12) on incidence of self-reported fall injury requiring medical care, acute stroke, myocardial infarction, and acute heart failure. We used multinomial logistic regression to consider fall injury only, any cardiovascular (CV) outcome, and both fall and CV outcome (compared to neither outcome), controlling for age at baseline and sex, to calculate net absolute changes in risk across increasing levels of AHC. We considered AHC classes first as a numeric predictor (where greater=more aggressive) and second as a categorical predictor. We calculated net effect of increasing AHC from one category to the next higher category, in units of absolute percentage points, with bootstrapped confidence intervals (95 %) around the net effect to determine statistical difference from zero. RESULTS: Two-year incidence of fall injury (11 % overall) increased with age and was more prevalent than any CV event (5% overall). Most of the sample (n=3676, 66 %) was classified in group 3 (BP 120-160 mmHg). Group 4, the over controlled group with BP< 120 mmHg, included n=1037 (19 %). The poorly controlled groups 1 and 2 were small (n=223 [4 %] and n=582 [11 %], respectively). When we considered AHC as a continuous predictor (greater=more aggressive), per level of AHC increased risk of fall injury (RR 1.15 [95 % CI 1.0-1.3]), but not cardiovascular events (RR=1.08 [.81- 1.44]) or both (RR=1.33 [.94-.1.9). When net harm was considered across advancing age, net harm was associated with group 4 (<120 mmHg) compared to group 3 (BP 120-160mmHg). The net harm associated with overly-treated BP ranged from2 absolute %-points at age 65, increasing to 10 absolute %-points at age 85, with net harm statistically different from zero above the age of 73 (Figure), mostly due to fall injury. There were no differences in net benefit or harm between group 3 (120-160 mmHg) compared to the poorly-controlled groups (1 and 2). CONCLUSIONS: Aggressiveness of BP control should be individualized by patient to steer clear of net harm, especially for older adults at advanced ages. Those with overly-controlled BP and at risk of net harm should be considered for de-escalation. (Figure Presented)

BACKGROUND: Very brief single-item screening questions (SISQs) for alcohol and other drug use can facilitate screening in health care settings, but are not widely used. Self-administered versions of the SISQs could ease barriers to their implementation. OBJECTIVE: We sought to validate SISQs for self-administration in primary care patients. DESIGN: Participants completed SISQs for alcohol and drugs (illicit and prescription misuse) on touchscreen tablet computers. Self-reported reference standard measures of unhealthy use, and more specifically of risky consumption, problem use, and substance use disorders, were then administered by an interviewer, and saliva drug tests were collected. PARTICIPANTS: Adult patients aged 21-65 years were consecutively enrolled from two urban safety-net primary care clinics. MAIN MEASURES: The SISQs were compared against reference standards to determine sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for alcohol and drug use. KEY RESULTS: Among the 459 participants, 22 % reported unhealthy alcohol use and 25 % reported drug use in the past year. The SISQ-alcohol had sensitivity of 73.3 % (95 % CI 65.3-80.3) and specificity of 84.7 % (95 % CI 80.2-88.5), AUC = 0.79 (95 % CI 0.75-0.83), for detecting unhealthy alcohol use, and sensitivity of 86.7 % (95 % CI 75.4-94.1) and specificity of 74.2 % (95 % CI 69.6-78.4), AUC = 0.80 (95 % CI 0.76-0.85), for alcohol use disorder. The SISQ-drug had sensitivity of 71.3 % (95 % CI 62.4-79.1) and specificity of 94.3 % (95 % CI 91.3-96.6), AUC = 0.83 (95 % CI 0.79-0.87), for detecting unhealthy drug use, and sensitivity of 85.1 (95 % CI 75.0-92.3) and specificity of 88.6 % (95 % CI 85.0-91.6), AUC = 0.87 (95 % CI 0.83-0.91), for drug use disorder. CONCLUSIONS: The self-administered SISQs are a valid approach to detecting unhealthy alcohol and other drug use in primary care patients. Although self-administered SISQs may be less accurate than the previously validated interviewer-administered versions, they are potentially easier to implement and more likely to retain their fidelity in real-world practice settings.

BACKGROUND: The popularity of electronic dance music and rave parties such as dance festivals has increased in recent years. Targeted samples of party-goers suggest high rates of drug use among attendees, but few nationally representative studies have examined these associations. METHODS: We examined sociodemographic correlates of rave attendance and relationships between rave attendance and recent (12-month) use of various drugs in a representative sample of US high school seniors (modal age: 18) from the Monitoring the Future study (2011-2013; Weighted N=7373). RESULTS: One out of five students (19.8%) reported ever attending a rave, and 7.7% reported attending at least monthly. Females and highly religious students were less likely to attend raves, and Hispanics, students residing in cities, students with higher income and those who go out for fun multiple times per week were more likely to attend. Rave attendees were more likely than non-attendees to report use of an illicit drug other than marijuana (35.5% vs. 15.6%, p<0.0001). Attendees were more likely to report use of each of the 18 drugs assessed, and attendees were more likely to report more frequent use (>/=6 times) of each drug (ps<0.0001). Controlling for sociodemographic covariates, frequent attendance (monthly or more often) was associated with higher odds of use of each drug (ps<0.0001). Frequent attendees were at highest risk for use of "club drugs." DISCUSSION: Findings from this study can help inform prevention and harm reduction among rave attendees at greatest risk for drug use.