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Introduction: Blacks in the United States experience greater persistent pain than non-Hispanic Whites across a range of medical conditions, but to our knowledge no longitudinal studies have examined the risk factors or incidence of persistent pain among Blacks experiencing common traumatic stress exposures such as after a motor vehicle collision (MVC). We evaluated the incidence and predictors of moderate to severe axial musculoskeletal pain (MSAP) and widespread pain six weeks after a MVC in a large cohort of Black adults presenting to the emergency department (ED) for care. Methods: This prospective, multi-center, cohort study enrolled Black adults who presented to one of 13 EDs across the US within 24 hours of a MVC and were discharged home after their evaluation. Data were collected at the ED visit via patient interview and self-report surveys at six weeks after the ED visit via internet-based, self-report survey, or telephone interview. We assessed MSAP pain at ED visit and persistence at six weeks. Multivariable models examined factors associated with MSAP persistence at six weeks post-MVC. Results: Among 787 participants, less than 1% reported no pain in the ED after their MVC, while 79.8 (95% confidence interval [CI], 77.1 -- 82.2) reported MSAP and 28.3 (95% CI, 25.5 -- 31.3) had widespread pain. At six weeks, 67% (95% CI, 64, 70%) had MSAP and 31% (95% CI, 28, 34%) had widespread pain. ED characteristics predicting MSAP at six weeks post-MVC (area under the curve = 0.74; 95% CI, 0.72, 0.74) were older age, peritraumatic dissociation, moderate to severe pain in the ED, feeling uncertain about recovery, and symptoms of depression. Conclusion: These data indicate that Blacks presenting to the ED for evaluation after MVCs are at high risk for persistent and widespread musculoskeletal pain. Preventive interventions are needed to improve outcomes for this high-risk group. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Discordance between self-perceived HIV risk and actual risk-taking may impede efforts to promote HIV testing among young adult men-who-have-sex-with-men (YMSM) in the United States (US). Understanding the extent of, and reasons for, the discordance of HIV risk self-perception, HIV risk-taking and voluntary HIV testing among black, Hispanic and white YMSM could aid in the development of interventions to increase HIV testing among this higher HIV risk population. HIV-uninfected 18–24-year-old black, Hispanic, and white YMSM were recruited from across the US through multiple social media websites. Participants were queried about their voluntary HIV testing history, perception of currently having an undiagnosed HIV infection, and condomless anal intercourse (CAI) history. We assessed the association between previous CAI and self-perceived possibility of currently having an HIV infection by HIV testing status using Cochran-Mantel-Haenszel testing. Of 2275 black, Hispanic and white social media-using 18–24 year-old YMSM, 21% had never been tested for HIV voluntarily, 87% ever had CAI with another man, 77% believed that it was perhaps possible (as opposed to not possible at all) they currently could have an undiagnosed HIV infection, and 3% who reported CAI with casual or exchange partners, but had not been tested for HIV, self-perceived having no possibility of being HIV infected. Of 471 YMSM who had not been HIV tested, 57% reported CAI with casual or exchange partners, yet self-perceived having no possibility of being HIV infected. Per the Cochran-Mantel-Haenszel test results, among those reporting HIV risk behaviors, the self-perception of possibly being HIV-infected was not greater among those who had never been tested for HIV, as compared to those who had been tested. Future interventions should emphasize promoting self-realization of HIV risk and translating that into seeking and accepting voluntary HIV testing among this higher HIV risk population. [ABSTRACT FROM PUBLISHER]

The article discusses the implication of providing information to patients regarding costs of emergency department routine HIV screening tests in the U.S., based on a survey among patients at Albany Medical Center in New York City from June 2013 through July 2014. The variables cited in the survey include demographic characteristics, willingness of patients to have an HIV test, and percentage of patients with health care insurance. An expert working group was convened to assist HIV patients.

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The Emergency Department (ED) appears to be an ideal place to conduct hepatitis C virus (HCV) screening. We aimed to estimate the prevalence of prior HCV test positivity among adult (18-64 year-old) patients at The Miriam Hospital and Rhode Island Hospital EDs, as well as the undiagnosed HCV antibody seroprevalence among patients with any self-reported injection or non-injection drug use who agreed to undergo rapid HCV antibody testing. The prevalence of prior HCV test positivity among 8,500 adult ED patients was approximately 4.6%, and the previously undiagnosed HCV antibody seroprevalence among 621 drug-using adult ED patients was 1.6%. Among the ten ED patients with a positive rapid HCV antibody test not previously diagnosed, eight were born after 1965 and six never had injected drugs. If current HCV screening recommendations were followed exclusively in this setting, this practice would have missed half of those with a positive rapid HCV antibody test. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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. [ABSTRACT FROM AUTHOR]

Objective To determine the proportion of emergency department (ED) patients who have been tested for human immunodeficiency virus (HIV) infection and assess if patient history of HIV testing varies according to patient demographic characteristics. Design From July 2005-July 2006, a random sample of 18-55-year-old English-speaking patients being treated for sub-critical injury or illness at a northeastern US ED were interviewed on their history of HIV testing. Logistic regression models were created to compare patients by their history of being tested for HIV according to their demography. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. Results Of 2107 patients surveyed who were not known to be HIV-infected, the median age was 32 years; 54% were male, 71% were white, and 45% were single/never married; 49% had private health-care insurance and 45% had never been tested for HIV. Of the 946 never previously tested for HIV, 56.1% did not consider themselves at risk for HIV. In multivariable logistic regression analyses, those less likely to have been HIV tested were male (OR: 1.32 [1.37-2.73]), white (OR: 1.93 [1.37-2.73]), married (OR: 1.53 [1.12-2.08]), and had private health-care insurance OR: 2.10 [1.69-2.61]). There was a U-shaped relationship between age and history of being tested for HIV; younger and older patients were less likely to have been tested. History of HIV testing and years of formal education were not related. Conclusion Almost half of ED patients surveyed had never been tested for HIV. Certain demographic groups are being missed though HIV diagnostic testing and screening programmes in other settings. These groups could potentially be reached through universal screening. [ABSTRACT FROM AUTHOR]

The objectives of this study were to estimate the incidence and identify the temporal patterns of visits to Rhode Island emergency departments (EDs) by adults who were sexually assaulted. Visits to all Rhode Island EDs from January 1995–June 2001 by adults who were sexually assaulted were identified using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9) codes. Medical records of these visits were reviewed. Frequency distributions of the assault characteristics and patient demographics were generated. Incidence rates (IRs) of ED visits after sexual assault were estimated using 2000 US Census data. Analyses of the temporal patterns of the ED visits after sexual assault were conducted. Of the 823 ED visits, 796 (96.7%) were by females and 27 (3.3%) were by males. The median age for females was 25 years (range, 18–96 years) and was 28 years (range, 18–87 years) for males. Among the female patients, 76.6% sustained a vaginal/anal assault. Among the male patients, 59.3% sustained an anal assault. The average annual IR of ED visits after sexual assault was 30.3/100,000/year for females and 1.2/100,000/year for males, which is a 25-fold greater incidence of these visits for females than males. ED visits after adult sexual assault were more frequent during warmer months and around 5 p.m. There was a gradual 43% increase in the IRs of ED visits after sexual assault over the 6.5-year period. These findings should help direct EDs to maximize supportive services when they are needed most often. [ABSTRACT FROM AUTHOR]

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% Cl 1.04, 1.58), not married (OR = 1.82, 95% Cl 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study that examined the frequency that inhaled corticosteroids (ICS) are prescribed to children with asthma exacerbations discharge in U.S. emergency departments (ED). It analyzes the 2005-2007 National Hospital Ambulatory Medical Care Survey (NHAMCS) database for ED for children with acute respiratory symptoms and asthma exacerbation. It concludes with a suggestion for ED clinicians to consider interventions to boost ICS prescriptions.

Background: Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain.Objectives: Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis.Methods: We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge.Results: Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90.Conclusions: Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications. [ABSTRACT FROM AUTHOR]

Purpose: The opioid epidemic in the United States continues to grow, particularly impacting rural communities served by critical access hospitals (CAHs) in Maine. Buprenorphine is an effective medication for the treatment of opioid use disorder (OUD) that can be successfully initiated in the emergency department (ED). However, many EDs have not implemented programs to initiate buprenorphine. This study sought to identify barriers and facilitators to successful implementation of buprenorphine programs inCAH EDs., Methods: Semistructured interviews were conducted with ED directors of Maine CAHs regarding barriers and facilitators to developing programs for ED-initiated buprenorphine. Seventeen Maine CAH EDs exist and 11 of their directors agreed to participate and completed interviews, which were audio-recorded, transcribed, and analyzed using a thematic approach., Results: Four themes and 11 subthemes were identified, including (1) compelled to act-directors' personal experiences with patients facilitated the development of buprenorphine programs in their EDs; (2) leadership and mentorship-peer mentorship from other CAH ED directors facilitated, and senior hospital administrators facilitated, or created a barrier in some cases; (3) stigma-fear that EDs would be overcrowded by drug-seeking patients was a common barrier; and (4) follow-up-finding appropriate outpatient follow-up for OUD patients created the greatest logistical barrier., Discussion: ED directors' clinical experience with OUD patients, supportive hospital leadership, and peer mentorship facilitated ED-initiated buprenorphine programs in rural Maine CAH EDs. Overcoming stigma, developing community outreach, and appropriate follow-up were the greatest barriers. Future research should focus on enhancing peer mentorship, administrative support, community outreach, and staff education., (© 2021 National Rural Health Association.)

Background: We conducted a systematic review of studies published in peer-reviewed journals on HIV screening programs conducted in pediatric emergency departments (PEDs) in the United States (US) with the objective of describing the methods, testing yields and challenges in these programs., Methods: We searched for full-text, English-language, original research articles focused on the conduct, development, initiation or implementation of any HIV screening program in a US PED through eight online databases (Pubmed (MEDLINE), Scopus, Embase, Cochrane, Web of Science, CINAHL, PsycInfo and Google Scholar) from their inception through July 2020. We also searched for articles on the websites of thirteen emergency medicine journals, 24 pediatric and adolescent health journals, and ten HIV research journals, and using the references of articles found through these searches. Data on HIV testing program components and yield of testing was extracted by one investigator independently and verified by a second investigator. Each program was summarized and critiqued., Results: Of the eight articles that met inclusion criteria, most involved descriptions of their HIV testing program, except for one that was focused on quality improvement of their program. Five described an opt-in and three an opt-out approach to HIV screening. Programs differed greatly by type of HIV test utilized and who initiated or performed testing. There were large variations in the percentage of patients offered (4.0% to 96.7%) and accepting (42.7% to 86.7%) HIV testing, and HIV seropositivity in the studies ranged from 0 to 0.6%. Five of the eight studies reported an HIV seropositivity greater than 0.1%, above Centers for Disease Control and Prevention recommended threshold for testing in a healthcare setting., Conclusions: The studies illustrate opportunities to further optimize the integration of HIV screening programs within US PEDs and reduce barriers to testing, improve efficiency of testing results and increase effectiveness of programs to identify cases. Future research should focus on advancing the methodology of screening programs beyond feasibility studies as well as conducting investigations on their implementation and longer-term sustainability., (© 2022. The Author(s).)

Introduction: African-Americans in the United States experience greater persistent pain than non-Hispanic Whites across a range of medical conditions, but to our knowledge no longitudinal studies have examined the risk factors or incidence of persistent pain among African-Americans experiencing common traumatic stress exposures such as after a motor vehicle collision (MVC). We evaluated the incidence and predictors of moderate to severe axial musculoskeletal pain (MSAP) and widespread pain six weeks after a MVC in a large cohort of Black adults presenting to the emergency department (ED) for care., Methods: This prospective, multi-center, cohort study enrolled Black adults who presented to one of 13 EDs across the US within 24 hours of a MVC and were discharged home after their evaluation. Data were collected at the ED visit via patient interview and self-report surveys at six weeks after the ED visit via internet-based, self-report survey, or telephone interview. We assessed MSAP pain at ED visit and persistence at six weeks. Multivariable models examined factors associated with MSAP persistence at six weeks post-MVC., Results: Among 787 participants, less than 1% reported no pain in the ED after their MVC, while 79.8 (95% confidence interval [CI], 77.1 - 82.2) reported MSAP and 28.3 (95% CI, 25.5 - 31.3) had widespread pain. At six weeks, 67% (95% CI, 64, 70%) had MSAP and 31% (95% CI, 28, 34%) had widespread pain. ED characteristics predicting MSAP at six weeks post-MVC (area under the curve = 0.74; 95% CI, 0.72, 0.74) were older age, peritraumatic dissociation, moderate to severe pain in the ED, feeling uncertain about recovery, and symptoms of depression., Conclusion: These data indicate that African-Americans presenting to the ED for evaluation after MVCs are at high risk for persistent and widespread musculoskeletal pain. Preventive interventions are needed to improve outcomes for this high-risk group.

Study Objective: 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., Methods: Participants were Spanish- or English-speaking adult patients randomly selected from 4 geographically spread, US, urban, safety-net EDs. Participants completed the 3 health literacy screening items, as well as the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E). Test performance characteristics, including receiver operating characteristics area under the curve, of the 3 health literacy screening items were estimated, as compared with the SAHL-S&E., Results: According to the SAHL-S&E, 36% of the 1,165 English speakers and 35% of the 1,605 Spanish speakers had lower health literacy. Areas under the curve for each health literacy screening item individually were: needing others to help read materials (English 0.59, 95% confidence interval [CI] 0.56 to 0.62; Spanish 0.58, 95% CI 0.56 to 0.61), problems learning because of difficulty reading (English 0.63, 95% CI 0.60 to 0.66; Spanish 0.59, 95% CI 0.56 to 0.62), and confidence with completing forms (English 0.62, 95% CI 0.59 to 0.65; Spanish 0.60, 95% CI 0.57 to 0.63). Areas under the curve for the 3 screening items combined were: English 0.66 (95% CI 0.63 to 0.70) and Spanish 0.62 (95% CI 0.59 to 0.64)., Conclusion: The 3 health literacy screening items performed poorly in identifying adult ED patients with lower health literacy. Higher-validity screening measures are needed to better serve the health care needs of this vulnerable population in the ED setting., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Among HIV-uninfected, social media-using black, Hispanic, and white young men who have sex with men (YMSM) who had condomless anal sex but had not been HIV tested within the past year, we aimed to determine the extent of discordance between perception of having an undiagnosed HIV infection and HIV risk-taking behaviors. Despite reporting condomless anal sex without HIV testing, 64% of 358 YMSM participants perceived having an undiagnosed HIV infection as "unlikely" and 12% as "impossible." Having a primary care provider and being Hispanic were associated with greater discordance. Interventions to decrease the discordance between perceived and actual HIV risk are needed for this higher HIV risk population.

Young adult men-who-have-sex-with-men (YMSM) continue to have among the highest incidence of HIV infection in the United States. Pre-exposure prophylaxis (PrEP) is an effective and safe method of preventing HIV infection; however, despite US Food and Drug Administration approval, utilization remains low, in part, due to structural barriers, particularly access to healthcare. In this study, we used social media to recruit black, Hispanic, and white HIV-uninfected 18- to 24-year-old YMSM. Participants completed an online survey about their sexual behavior, healthcare access, and previous use of PrEP. Of the 2297 YMSM surveyed, only 3.4% had used PrEP. PrEP use was associated with higher levels of education, living alone, older age, higher levels of sexual activity, and greater healthcare access, specifically having healthcare insurance and a clinic or primary care provider (PCP) from whom they received care. Among PrEP nonusers, 65% met at least one of the US Centers for Disease Control and Prevention recommended indications for PrEP use, and of these, 59% had healthcare insurance and received care in a clinic and/or had a PCP. Multi-variable multi-nomial logistic regression modeling identified disparities in access to healthcare by age, race/ethnicity, education, and region. Specifically, older YMSM, blacks and Hispanics, those with fewer years of formal education, and residents of the southern and the western United States were more likely to lack healthcare access. These results demonstrate both potential opportunities and barriers to the scale-up of PrEP among YMSM.

In 2012, the Centers for Medicare & Medicaid Services (CMS) instituted a Physician Quality Reporting System measure for screening and referring patients with elevated blood pressure (BP). The aims of this study were to (1) assess the reliability of ED triage BP as a metric to establish when the CMS threshold (≥120/80 mm Hg), and other clinically relevant BP thresholds (≥140/90 and ≥160/100 mm Hg) have been met, using BP measured with a highly accurate device (BpTRU) in the emergency department as the gold standard; and (2) determine whether correct identification varies by gender, race, or triage acuity. Using the BpTRU, we calculated the proportion of patients whose triage BP accurately indicated a need for further referral and treatment for hypertension according to three suggested BP thresholds (≥120/80, ≥140/90, and ≥160/100 mm Hg). Of 354 patients, the median age was 39 years, 48.9% were women, and 66.4% were White. At the three suggested BP thresholds (≥120/80, ≥140/90, and ≥160/100 mm Hg), 66.1%, 74.0%, and 88.8% of patients were confirmed to meet the CMS threshold, respectively. There were no differences by gender, race, or triage acuity. Emergency department triage BP would reliably identify elevated BP using the CMS threshold in up to two-thirds of those without known hypertension., (Copyright © 2017 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)

Objective: To estimate trends in hospitalizations and days of care of HIV-infected individuals in US hospitals from 1982 to 2010., Methods: Secondary data analysis of the National Hospital Discharge Survey., Results: Hospitalizations of HIV-infected individuals increased from 1982 to a peak of 216 086 by 1995, fell 36% by 1997, and then decreased to 118 236 by 2010. Days of care for HIV-uninfected individuals decreased 14.7% from 6.1 days in 1982 to 5.2 days in 2010 yet dropped 62.7% from 17.6 to 7.1 days for HIV-infected individuals. Hospitalized HIV-infected individuals were more likely than uninfected individuals to be male, black, 35 to 44 years old, Medicaid recipients, and be hospitalized in the northeast, in hospitals with more than 500 beds and in government-operated hospitals., Conclusions: Hospitalizations and days of care for HIV-infected individuals have decreased dramatically in recent years and at rates greater than for HIV-uninfected individuals yet involve some populations and affect certain hospitals disproportionately., (© The Author(s) 2015.)

In 1993, 2001, and 2006, the US Centers for Disease Control and Prevention (CDC) released revised recommendations aimed to expand HIV screening in health-care settings, increase the number of people who are aware of their infection, improve the health of those who are infected, and reduce HIV transmission. It is unclear how responsive health-care settings have been on a national level to these three successively revised sets of CDC recommendations. This study estimated the extent of HIV testing in US emergency departments (EDs), outpatient ambulatory medical care departments (OPDs), and physician offices among 13- to 64-year-olds from 1992 to 2010 to determine their responsiveness to CDC recommendations to expand HIV testing. The report includes data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS), which are national probability sample surveys conducted by the National Center for Health Statistics (NCHS) for CDC. Over the entire study period, HIV testing was significantly greater in OPDs than in EDs (p < 0.01) and physician offices (p < 0.01). Multivariable logistic regression analysis showed that Hispanic and Black patients and those receiving Medicaid were more likely to be tested for HIV. Logistic regression tests of trend for the entire study period did not demonstrate significant increases in testing at EDs (Odds ratios [OR] 1.00 [0.97-1.03]) or OPDs (OR 1.01 [0.98-1.04]). For physician offices, there was no change in HIV testing for 1993-1999 (OR 1.03 [0.99-1.06]), but there was a relative increase for the entire study period (OR 1.04 [1.02-1.06]) because of more HIV testing in 2009 and 2010 in this setting. However, there were no differences in HIV testing for each setting for the interval years after revised CDC HIV testing recommendations were released for 1993-2001, 2002-2006, and 2007-2010.

Background: The 2006 Centers for Disease Control and Prevention (CDC) revised recommendations for HIV testing in clinical settings contained seven specific changes to how health care facilities should provide HIV testing. These seven elements have been both supported and challenged in the lay and medical literature. Our first paper in BMC Medical Ethics presented an analysis of the three HIV testing procedural changes included in the recommendations. In this paper, we address the four remaining elements that concern HIV screening policy changes: (1) nontargeted HIV screening, (2) making HIV screening similar to screening for other treatable conditions, (3) increasing HIV screening without assured additional funding for linkage to care, and (4) making patients bear the costs of increased HIV screening in health care settings., Methods: We interviewed 25 members from the fields of US HIV advocacy, care, policy, and research about the ethical merits and demerits of the four changes to HIV screening policies. We performed a qualitative analysis of the participant responses in the interviews and summarized the major themes., Results: Participants commented that nontargeted HIV screening and making HIV screening similar to screening for other treatable medical conditions was ethical when it broadened the scope of people being tested for HIV. However, they believed it was unethical when it did not respect the exceptional nature of HIV and HIV testing. Some participants favored more testing regardless if there was assured additional funding for linkage to care or if patients might bear the costs of testing because they believed that merely alerting patients of their status was beneficial and would lead to positive consequences. Other participants found ethical flaws with testing without assured linkage to care and patients bearing the costs of testing, as this could discriminate against those who could not pay., Conclusions: Our findings suggest that there are fundamental ethical disagreements that shape views on CDC's recommended HIV testing policies. Differences remain on whether or not HIV remains an exceptional condition that requires it to be treated differently than other treatable conditions. Disagreement also exists on the responsibilities of health care providers and rights of patients in regards to screening in (1) the absence of assured linkage to care after an HIV diagnosis and (2) paying for the costs of HIV screening. Resolution of these disagreements is needed to serve the common goal of using testing to facilitate medical care for those who are HIV infected and for reducing HIV transmission.

Background: In 2006, the Centers for Disease Control and Prevention (CDC) recommended three changes to HIV testing methods in US healthcare settings: (1) an opt-out approach, (2) removal of separate signed consent, and (3) optional HIV prevention counseling. These recommendations led to a public debate about their moral acceptability., Methods: We interviewed 25 members from the fields of US HIV advocacy, care, policy, and research about the ethical merits and demerits of the three changes to HIV testing methods. We performed a qualitative analysis of the participant responses in the interviews and summarized the major themes., Results: In general, arguments in favor of the methods were based upon their ultimate contribution to increasing HIV testing and permitting the consequent benefits of identifying those who are HIV infected and linking them to further care., Conclusions: The prevailing theme of ethical concern focused on suspicions that the methods might not be properly implemented, and that further safeguards might be needed.

Objectives: We seek to identify and analyze, from a group of participants experienced with HIV screening, the perceived challenges and solutions to the ethical, financial, and legal considerations of emergency department (ED)-based HIV screening., Methods: We performed a qualitative analysis of the focus group discussions from the ethical, financial, and legal considerations portion of the inaugural National Emergency Department HIV Testing Consortium conference. Four groups composed of 20 to 25 consortium participants engaged in semistructured, facilitated focus group discussions. The focus group discussions were audiotaped and transcribed. A primary reader identified major themes and subthemes and representative quotes from the transcripts and summarized the discussions. Secondary and tertiary readers reviewed the themes, subthemes, and summaries for accuracy., Results: The focus group discussions centered on the following themes. Ethical considerations included appropriateness of HIV screening in the ED and ethics of key elements of the 2006 Centers for Disease Control and Prevention HIV testing recommendations. Financial considerations included models of payment and support, role of health care insurance, financial ethics and downstream financial burdens, and advocacy approaches. Legal considerations included the adequacy of obtaining consent, partner notification, disclosure of HIV results, difficulties in addressing special populations, failure of not performing universal screening, failure to notify a person of being tested, failure to notify someone of their test results, liability of inaccurate tests, and failure to link to care., Conclusion: This qualitative analysis provides a broadly useful foundation to the ethical, financial, and legal considerations of implementing HIV screening programs in EDs throughout the United States., (Copyright © 2011. Published by Mosby, Inc.)

When in 2006 the Centers for Disease Control and Prevention issued revised recommendations for HIV testing in health care settings, vocal opponents charged that use of an "opt-out" approach to presenting HIV testing to patients; the implementation of nontargeted, widespread HIV screening; the elimination of a separate signed consent; and the decoupling of required HIV prevention counseling from HIV testing are unethical. Here we undertake the first systematic ethical examination of the arguments both for and against the recommendations. Our examination reveals that the ethical concerns raised by the critics predominantly pertain not to ethically suspect elements of the recommendations themselves, but to suspicions that they will be implemented improperly. It has not been shown that the recommendations cannot be implemented properly. Here we show that in the United States the recommendations are morally justifiable and that safeguards or regulatory oversight may serve to ensure that the recommendations are properly implemented.

Objectives: We aimed to create a system for predicting which male emergency department (ED) patients with suspected chlamydial and/or gonococcal urethritis would have laboratory-confirmed infections based on clinical factors available at the initial ED encounter., Methods: We used statistical models to develop a system to predict either the presence or absence of laboratory-confirmed chlamydial and/or gonorrheal urethritis based on patient demographics and presenting symptoms. Data for the system were extracted from a retrospective chart review of adult male patients who were suspected of having, and were tested for, chlamydial and/or gonococcal urethritis at an adult, urban, northeastern United States, academic ED from January 1998 to December 2004., Results: Among the 822 patients tested, 29.2% had chlamydia, gonorrhea, or both infections; 13.8% were infected with chlamydia alone, 12.1% were infected with gonorrhea alone, and 3.3% were infected with both. From the statistical models, the following factors were predictive of a positive laboratory test for chlamydia and/or gonorrhea: age < or = 24 years, penile discharge, sexual contact with someone known to have chlamydia and/or gonorrhea, and not having health care insurance. A system using a hierarchical grouping of these factors based on the predicted probabilities of a laboratory-confirmed chlamydial and/or gonococcal urethritis, paired with baseline ED prevalence of these infections, was confirmed through internal validation testing to modestly predict which patients had or did not have a laboratory-confirmed infection., Conclusions: This system of a combination of risk factors available during the clinical encounter in the ED modestly predicts which adult male patients suspected of having chlamydial and/or gonorrheal urethritis are more likely to have or not have a laboratory-confirmed infection. A prospective study is needed to create and validate a clinical prediction rule based on the results of this system.

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 department (ED) presentation, antibiotic usage and patient admission., Methods: We present a retrospective chart review of adults treated for human bites. Multivariable logistic regression models used demographic characteristics and bite circumstances and characteristics as factors associated with ED presentation more than 24 hours after the bite, antibiotic usage and hospital admission., Results: Of the 388 patients evaluated for a human bite, 66.5% were bitten during an altercation; 23.8% presented more than 24 hours after the bite; 50.3% were bitten on the hands or fingers, 23.5% on an extremity and 17.8% on the head or neck. Only 7.7% of all patients sustained closed-fist injuries; the majority had occlusional or other kinds of bites. The majority of patients (77.3%) received antibiotics and 11.1% were admitted to hospital. Patients who had greater odds of presenting more than 24 hours after the bite were black (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.02-3.13), Hispanic (OR 2.68, 95% CI 1.22-5.89) and those who had a non-occupational bite (OR 3.87, 95% CI, 1.68-8.90). Patients had a greater chance of receiving antibiotics if they were bitten during an altercation (OR 1.87, 95% CI, 1.09-3.20) and were bitten on the hands or fingers (OR 2.23, 95% CI 1.31-3.80). Patients had a greater chance of being admitted to the hospital if they were bitten during an altercation (OR 4.91, 95% CI 1.65-14.64), bitten on the hands or fingers (OR 5.26, 95% CI, 1.74-15.87) and if they presented >or= 24 hours after the bite., Conclusion: Most patients presented to the ED within 24 hours of their injury and received antibiotics. The circumstances surrounding the bite appeared to be associated with delay to ED presentation, receipt of antibiotics and admission to the hospital. There are ethnic background differences in delay to ED presentation. ED clinicians in our study favour antibiotic usage and admission based on the body location of the bite, despite little evidence to support these practices.

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.

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.

Objectives: (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., Methods: The current study involved a retrospective analysis of all visits to an urban, northeastern, United States pediatric ED from 1995 to 2001. Visits for human bites were identified by International Classification of Disease, Ninth Revision, Clinical Modification codes using 2 separate computerized billing databases. Data were extracted from 2 prior published studies for the comparative portion of the study. Frequency estimates and 95% confidence intervals were created using STATA7., Results: For the current study, there were 115 visits for human bites, which comprised 0.04% [0.03-0.05] of total visits to this pediatric ED. Bite visits as a percentage of pediatric ED visits remained the same during the 7 years of the current study. For all 3 pediatric EDs, human bites consisted of much less than 1% of the overall patient volume. The majority (65% [55.8-73.9]) of the patients in the current study were male. When adjusted for the frequency of all patient visits by gender, there was no statistically significant difference in percentage of visits for human bites between males and females (0.05% [0.039-0.063] vs. 0.03% [0.023-0.044]) in the current study. Prior studies did not reveal a statistically significant predominance of males presenting for human bites. As a percentage of visits by age group, human bites were more frequent among adolescents in the current study. Altercations and child play were reported approximately equally as the circumstances contributing to the bites in the current study, although altercations were reported more often in older age groups. In all 3 studies, fewer than 14% of patients were admitted and over 80% presented within 12 or 24 hours after the bite., Conclusions: Pediatric ED visits for human bites are infrequent and from the current study data, the frequency of visits for these injuries appears to be currently stable. Altercations may not be the main circumstances surrounding all pediatric human bites, yet altercations and human bites might be jointly associated with adolescence. The current study results suggest that most pediatric ED human bite patients are male, although males may not necessarily sustain human bites more frequently than females. Visits for human bite injuries may increase in frequency with age, in comparison to visits for other medical conditions.

The authors report on sexual orientation disclosure issues considered by lesbian, gay, and bisexual students and physicians during their medical school and residency selection process.

To determine how often US ED practitioners have prescribed HIV post-exposure prophylaxis (HIV PEP) and to discern how willing they are to offer it to patients, the authors surveyed 600 ED practitioners attending a national conference. According to their self-report, 11% had taken HIV PEP themselves. Sixty-eight percent had prescribed HIV PEP at some time. Of these, 92% had treated needlestick-injured health care workers, 48% sexual assault survivors, and 49% nonhealth care needlestick-injured persons. ED practitioners were more willing to offer HIV PEP after exposures to HIV-infected or high-risk sources than unknown or low- risk sources, as well as after sexual assault than consensual sex. Female practitioners, those who had themselves taken HIV PEP, resident physicians, and ED practitioners with fewer than 6 years of clinical practice were generally more apt to offer HIV PEP. Educational campaigns appear to be necessary to help ED practitioners determine when HIV PEP is appropriate.

Objectives: To determine emergency department (ED) practitioner willingness to offer emergency contraception (EC) following sexual assault and consensual sex, and to compare responses of practitioners from states whose laws permit the refusal, discussion, counseling, and referral of patients for abortions (often called "opt-out" or "abortion-related conscience clauses") with those of practitioners from states without these laws., Methods: Using a structured questionnaire, a convenience sample of ED practitioners attending a national emergency medicine meeting was surveyed., Results: The 600 respondents were: 71% male, 29% female; 34% academic, 26% community, and 33% resident physicians; and 7% nurse practitioners and physician assistants. Many respondents (88%) were inclined to offer EC to those sexually assaulted by unknown assailants. More practitioners said they were willing to offer EC if the assailant was known to be HIV-infected rather than if the assailant had low HIV risk factors (90% vs. 79%, p < 0.01). More respondents would prescribe EC after sexual assault than consensual sex (88% vs. 73%, p < 0.01). The rates of willingness to offer EC were the same for practitioners in states with "abortion-related conscience clauses" and those from other states., Conclusions: Most ED practitioners said they were willing to offer EC. Although the risk of pregnancy exists after consensual sex, practitioners were less willing to prescribe EC after those exposures than for sexual assault. "Abortion-related conscience clauses" did not seem to influence willingness to offer EC.