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Childhood trauma is a known risk factor for trauma and stress-related disorders in adulthood. However, limited research has investigated the impact of childhood trauma on brain structure linked to later posttraumatic dysfunction. We investigated the effect of childhood trauma on white matter microstructure after recent trauma and its relationship with future posttraumatic dysfunction among trauma-exposed adult participants (n= 202) recruited from emergency departments as part of the AURORA Study. Participants completed self-report scales assessing prior childhood maltreatment within 2-weeks in addition to assessments of PTSD, depression, anxiety, and dissociation symptoms within 6-months of their traumatic event. Fractional anisotropy (FA) obtained from diffusion tensor imaging (DTI) collected at 2-weeks and 6-months was used to index white matter microstructure. Childhood maltreatment load predicted 6-month PTSD symptoms (b = 1.75, SE = 0.78, 95% CI = [0.20, 3.29]) and inversely varied with FA in the bilateral internal capsule (IC) at 2-weeks (p= 0.0294, FDR corrected) and 6-months (p= 0.0238, FDR corrected). We observed a significant indirect effect of childhood maltreatment load on 6-month PTSD symptoms through 2-week IC microstructure (b = 0.37, Boot SE = 0.18, 95% CI = [0.05, 0.76]) that fully mediated the effect of childhood maltreatment load on PCL-5 scores (b = 1.37, SE = 0.79, 95% CI = [−0.18, 2.93]). IC microstructure did not mediate relationships between childhood maltreatment and depressive, anxiety, or dissociative symptomatology. Our findings suggest a unique role for IC microstructure as a stable neural pathway between childhood trauma and future PTSD symptoms following recent trauma. Notably, our work did not support roles of white matter tracts previously found to vary with PTSD symptoms and childhood trauma exposure, including the cingulum bundle, uncinate fasciculus, and corpus callosum. Given the IC contains sensory fibers linked to perception and motor control, childhood maltreatment might impact the neural circuits that relay and process threat-related inputs and responses to trauma.

Considerable racial/ethnic disparities persist in exposure to life stressors and socioeconomic resources that can directly affect threat neurocircuitry, particularly the amygdala, that partially mediates susceptibility to adverse posttraumatic outcomes. Limited work to date, however, has investigated potential racial/ethnic variability in amygdala reactivity or connectivity that may in turn be related to outcomes such as post-traumatic stress disorder (PTSD). Participants from the AURORA study (n= 283), a multisite longitudinal study of trauma outcomes, completed functional magnetic resonance imaging and psychophysiology within approximately two-weeks of trauma exposure. Seed-based amygdala connectivity and amygdala reactivity during passive viewing of fearful and neutral faces were assessed during fMRI. Physiological activity was assessed during Pavlovian threat conditioning. Participants also reported the severity of posttraumatic symptoms 3 and 6 months after trauma. Black individuals showed lower baseline skin conductance levels and startle compared to White individuals, but no differences were observed in physiological reactions to threat. Further, Hispanic and Black participants showed greater amygdala connectivity to regions including the dorsolateral prefrontal cortex (PFC), dorsal anterior cingulate cortex, insula, and cerebellum compared to White participants. No differences were observed in amygdala reactivity to threat. Amygdala connectivity was associated with 3-month PTSD symptoms, but the associations differed by racial/ethnic group and were partly driven by group differences in structural inequities. The present findings suggest variability in tonic neurophysiological arousal in the early aftermath of trauma between racial/ethnic groups, driven by structural inequality, impacts neural processes that mediate susceptibility to later PTSD symptoms.

To derive and initially validate a brief bedside clinical decision support tool that identifies emergency department (ED) patients at high risk of substantial, persistent posttraumatic stress symptoms after a motor vehicle collision.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.annemergmed.2009.04.021 Byline: Arun D. Nagdev, Roland C. Merchant, Alfredo Tirado-Gonzalez, Craig A. Sisson, Michael C. Murphy Abstract: Among adult emergency department (ED) patients undergoing central venous catheterization, we determine whether a greater than or equal to 50% decrease in inferior vena cava diameter is associated with a central venous pressure of less than 8 mm Hg. Author Affiliation: Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI Article History: Received 15 October 2008; Revised 14 April 2009; Accepted 29 April 2009 Article Note: (footnote) Supervising editor: David T. Overton, MD, MBA, Author contributions: ANN conceived of the study, oversaw the data collection, and participated in the analysis and preparation of the article. RCM conducted the data analysis and prepared the article. ANN, AT-G, CAS, and MCM participated in the data collection. AT-G, CAS, and MCM participated in the review of the preparation of the article. ANN takes responsibility for the paper as a whole., Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement., Publication date: Available online June 25, 2009., Please see page 291 for the Editor's Capsule Summary of this article.

ABSTRACT Objectives: Evidence and consensus on best practices on the management of human bite injuries is lacking. Our objective was to identify factors that are associated with delay to emergency [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.annemergmed.2005.07.001 Byline: Megan L. Ranney, Erin M. Gee, Roland C. Merchant Abstract: In October 2004, the American College of Emergency Physicians Council joined more than 60 other health professional organizations in supporting the nonprescription availability of emergency contraception. This article reviews the history, efficacy, and safety of emergency contraception; the efforts toward making emergency contraception available without a prescription in the United States; the arguments for and against nonprescription availability of emergency contraception; and the potential impact nonprescription availability could have on the practice of emergency medicine in the United States. Author Affiliation: Department of Emergency Medicine, Brown Medical School, Providence, RI Article History: Received 9 May 2005; Revised 21 June 2005; Accepted 1 July 2005 Article Note: (footnote) Supervising editor: Debra E. Houry, MD, MPH Funding and support: Dr. Merchant is supported by a Career Development grant from the National Institute for Allergy and Infectious Diseases, National Institutes of Health, K23 AI060363. Publication dates: Available online September 13, 2005. Reprints not available from the authors.

In response to concerns about the continued care and safety of critically ill and injured patients, our academic, urban, tertiary care, level I trauma center adult emergency department (ED) created an advanced practice provider (APP)-staffed critical care step-down unit (CCSU). We conducted semistructured interviews of ED physicians, APPs, and nursing staff about the value added by the CCSU as well as suggestions for its improvement. The results from the interviews showed staff were highly complimentary of the CCSU and recommended expansion of its hours and APP staffing, but indicated areas of improvement. Future research can evaluate how implementation of stakeholder suggestions improved the CCSU’s operations.

We determine whether an emergency department (ED)–initiated fall-prevention intervention can reduce subsequent fall-related and all-cause ED visits and hospitalizations in older adults.

Brief, easily administered, and valid health literacy assessment tools are needed to optimize health care delivery in the emergency medicine setting. Three health literacy screening items have been proposed to assess health literacy in outpatient settings. We investigated their ability to identify English- and Spanish-speaking adult emergency department (ED) patients with lower health literacy.

Objectives: In the United States, all men who have sex with men (MSM) were banned from donating blood from 1985 through 2015. In 2016, the guideline was amended such that men who had sexual contact with other men within the previous 12 months could not donate blood. We aimed to identify blood donation practices and their relationship with HIV risk and testing among young adult MSM (YMSM) at risk for having HIV.Methods: In 2014, we recruited HIV-negative non-Hispanic black, Hispanic, and non-Hispanic white YMSM aged 18-24 from across the United States through social media platforms to complete an online survey. Among these YMSM who previously donated blood, we conducted a secondary analysis examining the relationship between having donated blood within the past 12 months and sexual risk behavior from recent condomless anal intercourse (CAI), HIV testing, and self-perceived risk of having an undiagnosed HIV infection.Results: Of the 2261 YMSM surveyed, 1104 (48.8%) had ever previously donated blood and 305 (13.5%) had donated blood within the past 12 months. Of the 305 blood donors, 50 (16.4%) had ever had CAI before their most recent blood donation. Among YMSM who donated blood, past–12-month blood donation was more likely among YMSM who never had CAI (adjusted odds ratio [aOR] = 1.84; 95% confidence interval [CI], 1.24-2.73) than among YMSM who had CAI and more likely among YMSM who believed it was not possible at all that they had an undiagnosed HIV infection (aOR = 1.57; 95% CI, 1.14-2.16) than among YMSM who believed there was any possibility of having an undiagnosed HIV infection; it was not related to past–12-month HIV testing.Conclusions: YMSM donated blood frequently, suggesting that the deferral process in place did not prevent YMSM from donating blood. The current donor screening process should be reconsidered if it is to prevent YMSM from donating blood. Future research could identify screening questions that permit YMSM with a low risk of HIV infection to donate blood while maintaining the safety of the blood supply.

ObjectivesAssess the 12-month efficacy of a brief intervention (BI) on reducing drug use and increasing drug treatment services utilisation among adult emergency department (ED) patients.MethodsThis randomised, controlled trial enrolled 18–64-year-old ED patients needing a drug use intervention. Treatment arm participants received a tailored BI while control arm participants only completed the study questionnaires. Self-reported past 3-month drug use and engagement in drug treatment services were compared by study arm at 3-month intervals over 1 year. Multiple imputations were performed to overcome loss-to-follow-up.ResultsOf the 1030 participants, follow-up completion ranged 55%–64% over the four follow-ups. At 12 months, the two study arms were similar in regards to mean: (1) proportion reporting any drug use (treatment: 67.1% (61.6 to 72.6), control: 74.4% (69.4 to 79.4)); (2) drug use frequency on a five-point scale (treatment: 3.7 (3.3 to 4.2), control: 4.6 (4.0 to 5.2)); (3) total days of drug use (treatment: 28.3 (23.2 to 33.4), control: 33.4 (28.5 to 38.2)); (4) most number of times drugs used/day (treatment: 4.6 (3.6 to 5.5), control: 6.1 (4.8 to 7.3)) and (5) typical number of times drugs used/day (treatment: 3.3 (2.5 to 4.1), control: 5.1 (3.9 to 6.2)). Utilisation of drug treatment services also was similar by study arm. In multivariable regression analyses, patients who were homeless or had higher drug use at baseline continued to have greater drug use in follow-up.ConclusionsAmong adult ED patients requiring a drug use intervention, this BI did not decrease drug use or increase drug treatment services utilisation over a 12-month period more than the control condition.Trial registration numberNCT01124591; Pre-trial.

The Montpellier protocol for intubating patients in the intensive care unit (ICU) is associated with a decrease in intubation-related complications. We sought to determine if implementation of a simplified version of the Montpellier protocol that removed selected components and allowed for a variety of pre-oxygenation modalities increased first-pass intubation success and reduced intubation-related complications.

Measurement of inferior vena cava collapsibility (cIVC) by point-of-care ultrasound (POCUS) has been proposed as a viable, non-invasive means of assessing fluid responsiveness. We aimed to determine the ability of cIVC to identify patients who will respond to additional intravenous fluid (IVF) administration among spontaneously breathing critically-ill patients.

This study's objective was to determine how frontline physicians perceived telehealth for older adults with sensory impairments, cognitive impairments, mobility challenges, or those receiving end-of-life care. We conducted a multiple-methods study of US emergency, geriatric, and primary care physicians. Phase 1 involved semi-structured interviews with 48 physicians on their experiences using telehealth with older adults. In phase 2, we used those qualitative findings to generate a web-based survey administered to 74 physicians. In phase 3, we reintegrated qualitative data to enrich survey results. We identified 3 key findings: (1) 50% of emergency physicians, 33% of geriatricians, and 18% of primary care physicians considered telehealth to be a poor substitute for providing end-of-life care (p= .68); (2) for hearing, vision, and cognitive impairments, 61%, 58%, and 54%, respectively, saw telehealth as a good or fair substitute for providing care (p= .14); and (3) 98% indicated that telehealth was a good or fair substitute for in-person care for those with mobility impairment (p< .001). Preferences and comfort using telehealth with older adults vary by clinical context, patient population, and physician specialty, requiring tailored adaptations.

Prior sexual trauma (ST) is associated with greater risk for posttraumatic stress disorderafter a subsequent traumatic event; however, the underlying neurobiological mechanisms remain opaque. We investigated longitudinal posttraumatic dysfunction and amygdala functional dynamics following admission to an emergency department for new primarily non-ST in participants with and without previous ST.

Population-level SARS-CoV-2 immunological protection is poorly understood but can guide vaccination and non-pharmaceutical intervention priorities. Our objective was to characterise cumulative infections and immunological protection in the Dominican Republic.

Despite increased concern about prescription opioid misuse among older adults, there is limited work examining the best means to identify misuse by older adults. The goal of this investigation was to examine the performance the Prescription Drug Use Questionnaire Patient Version (PDUQp), in detecting prescription opioid misuse and prescription opioid use disorders among adult emergency department (ED) patients aged 50 years and older.

This study aimed to understand current patterns of energy drink use and compare the extent of usage of energy drinks and other commonly used and misused substances between adolescent (13–17-years-old) and young adult (18–25-years-old) emergency department (ED) patients.

Background.Blood and body fluid exposures are frequently evaluated in emergency departments (EDs). However, efficient and effective methods for estimating their incidence are not yet established.Objective.Evaluate the efficiency and accuracy of estimating statewide ED visits for blood or body fluid exposures using International Classification of Diseases, Ninth Revision(ICD-9), code searches.Design.Secondary analysis of a database of ED visits for blood or body fluid exposure.Setting.EDs of 11 civilian hospitals throughout Rhode Island from January 1, 1995, through June 30, 2001.Patients.Patients presenting to the ED for possible blood or body fluid exposure were included, as determined by prespecified ICD-9 codes.Methods.Positive predictive values (PPVs) were estimated to determine the ability of 10 ICD-9 codes to distinguish ED visits for blood or body fluid exposure from ED visits that were not for blood or body fluid exposure. Recursive partitioning was used to identify an optimal subset of ICD-9 codes for this purpose. Random-effects logistic regression modeling was used to examine variations in ICD-9 coding practices and styles across hospitals. Cluster analysis was used to assess whether the choice of ICD-9 codes was similar across hospitals.Results.The PPV for the original 10 ICD-9 codes was 74.4% (95% confidence interval [CI], 73.2%–75.7%), whereas the recursive partitioning analysis identified a subset of 5 ICD-9 codes with a PPV of 89.9% (95% CI, 88.9%–90.8%) and a misclassification rate of 10.1%. The ability, efficiency, and use of the ICD-9 codes to distinguish types of ED visits varied across hospitals.Conclusions.Although an accurate subset of ICD-9 codes could be identified, variations across hospitals related to hospital coding style, efficiency, and accuracy greatly affected estimates of the number of ED visits for blood or body fluid exposure.

Objectives. CDC 2006 recommendations for new HIV testing methods in U.S. health-care settings (opt-out approach, general medical consent, and optional prevention counseling) have been the subject of a public ethical debate. Ethical concerns might limit their implementation and affect expanded HIV screening efforts. We compared clinicians' and patients' perspectives on the ethical concerns raised about, justifications provided in support of, and preferences for the 2006 CDC-recommended HIV testing methods for the U.S. health-care setting, in contrast with the 2001 CDC-recommended HIV testing methods (opt-in approach, specific written consent, and mandatory prevention counseling).Methods. We conducted a non-inferiority trial and survey of 249 clinicians and random samples of 1,013 of their patients at three emergency departments and three ambulatory care clinics at university-affiliated hospitals in Rhode Island from June to December 2007.Results. Clinicians found the 2006 CDC HIV testing methods to be more ethically concerning than the 2001 testing methods (i.e., ethically inferior), while patients had few ethical concerns. In regard to ethical justifications cited for the 2006 CDC HIV testing methods, clinicians were more supportive of the ethical justifications cited for using an opt-out approach and general medical consent, while patients were more supportive of the justifications for optional HIV prevention counseling. Clinicians showed a relatively greater preference for the opt-out approach and use of general medical consent, while patients had a relatively greater preference for optional HIV prevention counseling.Conclusions. Clinicians and their patients hold divergent ethical perspectives on CDC's 2006 HIV testing methods. The results indicate an opportunity to review not only these but also future HIV testing recommendations, as well as how they are presented for implementation.

ABSTRACTObjective:Our goal was to gain a better understanding of the femoral vessel anatomy as it relates to central venous cannulation. The primary objective of this study was to use bedside ultrasonography to determine the amount of exposed femoral vein at three sites corresponding to surface anatomy of the landmark-based procedure.Methods:This cross-sectional study enrolled a random sample of 180 adult patients presenting to a large urban academic emergency department. Subjects underwent standardized ultrasonography to identify and measure the depth and diameter of the femoral vessels and amount of exposed femoral vein at the level of the inguinal ligament (0 cm) 2 cm and 4 cm below. Repeated measures analysis of variance was used to determine significant relationships between vessel measurements and distance from the inguinal ligament.Results:The median age was 44.5 (range 19–90) years; 101 patients were male. The mean (± SD) percentage of exposed vein at the inguinal ligament was 83% (± 21). This decreased significantly (p< 0.01) with increasing distance from the inguinal ligament: 65% (± 25) at 2 cm and 56% (± 30) at 4 cm. At every distance away from the inguinal ligament, there were some subjects with no vein exposed.Conclusion:This study demonstrates significant overlap of the femoral vessels at sites where landmark-based femoral vein cannulation is often attempted. Our results suggest that ultrasound guidance would be beneficial as femoral vein cannulation may be difficult or impossible in certain individuals owing to anatomic variations.

Objectives. We assessed emergency department (ED) patient acceptance of opt-in, rapid human immunodeficiency virus (HIV) screening and identified demographic characteristics and HIV testing-history factors associated with acceptance of screening.Methods. A random sample of 18- to 55-year-old ED patients was offered rapid HIV screening. Patient acceptance or decline of screening and the reasons for acceptance or decline were analyzed with multivariable regression models. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated for the logistic regression models.Results. Of the 2,099 participants, 39.3% accepted HIV screening. In a multinomial regression model, participants who were never married/not partnered, did not have private health insurance, and had 12 or fewer years of education were more likely to be screened due to concern about a possible HIV exposure. In a multivariable logistic regression model, the odds of accepting screening were greater among those who were younger than 40 years old (OR=1.61, 95% CI 1.32, 2.00), nonwhite (OR=1.28, 95% CI 1.04, 1.58), not married (OR=1.82, 95% CI 1.44, 2.28), lacking private health insurance (OR=1.40, 95% CI 1.13, 1.74), and who had 12 or fewer years of education (OR=1.43, 95% CI 1.16, 1.75). Despite use of a standardized protocol, patient acceptance of screening varied by which research assistant asked them to be screened. Patients not previously tested for HIV who were white, married, and 45 years or older and who had private health insurance were more likely to decline HIV screening.Conclusions. In an opt-in, universal, ED HIV screening program, patient acceptance of screening varied by demography, which indicates that the impact of such screening programs will not be universal. Future research will need to determine methods of increasing uptake of ED HIV screening that transcend patient demographic characteristics, HIV testing history, and motivation for testing.

Objectives:To determine if respondents differed by their demography (age group, race or ethnicity, and insurance status) in their tendency to correctly answer knowledge‐based questions when they were in an agree‐disagree instead of a multiple‐choice format.

(1) Using clearly defined methods, provide a current assessment of the epidemiology of human bites sustained by pediatric patients evaluated at a pediatric ED; (2) Compare the frequency, demography, locations, and management of these injuries from the results of the current study to the 2 prior ED studies on pediatric human bites; and (3) Determine if the frequency of these injuries varies by year, gender, or body location.

The Brown University AIDS Program and the Rhode Island Department of Health joined with health care practitioners, researchers, and representatives of community-based health, social service, and advocacy organizations to create comprehensive guidelines on nonoccupational HIV postexposure prophylaxis for the state of Rhode Island. These guidelines offer health care practitioners detailed advice on the evaluation and management of blood or body fluid exposures outside the health care setting, e.g., through sexual assault, consensual sex, injecting-drug use, or needlestick injuries. In these circumstances, HIV postexposure prophylaxis serves those for whom primary prevention measures have failed or were impractical or impossible.The guidelines represent the end product of coordination among private and public, academic and nonacademic, clinician and layperson groups committed to decreasing the incidence of HIV infections in the state of Rhode Island. The guidelines serve as both a resource for health care practitioners and a means of educating them on this method of HIV prevention.

Objectives:To determine the frequency and type of patient visits for blood or body fluid exposures to a large, urban emergency department (ED); to ascertain the frequency that human immunodeficiency virus (HIV) post‐exposure prophylaxis (PEP) was prescribed for these exposures; and to compare HIV PEP usage by patient group, occupation, and exposure type. Methods:Retrospective medical record review of ED patient visits (January 1, 1995, through June 30, 2001) extracted from two separate billing record computerized databases using 14 ICD‐9 codes that defined blood or body fluid exposures. Results:Of the 1,436 visits, 22% were by health care workers (HCWs) and 78% by non‐HCW adults, adolescents, or children. Sixty percent of the HCWs sustained needlestick or sharp injuries, 73% of non‐HCW adults had human bites, and 81% of adolescents and children had sexual exposures. Nurses were the largest group of HCWs, whereas police, correction officers, and security guards were the largest group of non‐HCWs exposed at work. HCWs and non‐HCW adults who sustained nonsexual exposures were much more likely to present for an evaluation within 24 hours than adolescents or children who suffered sexual assault (p < 0.001). HIV PEP was prescribed 143 times: 92 to HCWs and 51 to all other patients. HIV PEP was most often prescribed to HCWs sustaining needlestick injuries. Conclusions:The majority of patients were not HCWs, which attests to the need for national, nonoccupational blood or body fluid management guidelines. There may be particular groups who would benefit from educational campaigns informing them of the need for early‐intervention, postexposure measures to prevent an HIV infection.

US emergency department physicians surveyed were more likely to offer hepatitis B prophylaxis to patients after unknown hepatitis B status needlestick injuries than sexual exposures, especially consensual sex. There was no difference in willingness to offer prophylaxis with respect to patient occupation or age or with respect to ED physicians' demographic and professional characteristics.