Suicidal ideation and sobriety: Should acute alcohol intoxication be taken into account for psychiatric evaluation?

BACKGROUND: When evaluating an emergency department (ED) patient who presents with suicidal ideation, it is a common practice to wait until the patient's ethanol level is known or calculated to be less than 80 mg/dl to evaluate patient safety. We know of no study that establishes an association between the degree of alcohol intoxication based on a blood alcohol level (BAL) and reported suicidal ideation (SI) upon recovery. METHODS: We conducted a retrospective review of patients evaluated in a Midwestern ED for the calendar year 2017. Cases were selected if they had a psychiatric social work consult and a blood alcohol level drawn while in the ED. Patients were selected on the same 2 days each week throughout the year to meet the sample size requirements of the study, resulting in 1084 cases for review. Chi-square analysis was used to evaluate the relationship between suicidal ideation and alcohol intoxication as defined by a BAL ≥80 mg/dl. RESULTS: Among patients presenting with suicidal ideation and a concurrent BAL ≥80 mg/dl, 69% no longer reported suicidal ideation when their BAL was <80 mg/dl, compared to 38% for patients without a positive BAL on presentation (chi-square, p = 0.000012). CONCLUSION: Our data show that patients presenting to the ED with complaints related to suicidal behavior who have a BAL ≥80 mg/dl are more likely to no longer endorse having suicidal ideation once their BAL is < 80 mg/dl than patients with similar presenting complaints and no alcohol intoxication. This finding supports the common ED practice of re-assessing suicidal ideation among individuals who are initially intoxicated once their BAL has decreased below 80 mg/dl.

COVID-19 vaccine hesitancy among patients in two urban emergency departments.

BACKGROUND: Widespread vaccination is an essential component of the public health response to the COVID-19 pandemic, yet vaccine hesitancy remains pervasive. This prospective survey investigation aimed to measure the prevalence of vaccine hesitancy in a patient cohort at two urban emergency departments (EDs) and characterize underlying factors contributing to hesitancy. METHODS: Adult ED patients with stable clinical status (Emergency Severity Index 3-5) and without active COVID-19 disease or altered mental status were considered for participation. Demographic elements were collected as well as reported barriers/concerns related to vaccination and trusted sources of health information. Data were collected in person via a survey instrument proctored by trained research assistants. RESULTS: A total of 1,555 patients were approached, and 1,068 patients completed surveys (completion rate = 68.7%). Mean (±SD) age was 44.1 (±15.5) years (range = 18-93 years), 61% were female, and 70% were Black. A total of 31.6% of ED patients reported vaccine hesitancy. Of note, 19.7% of the hesitant cohort were health care workers. In multivariable regression analysis, Black race (odds ratio [OR] = 4.24, 95% confidence interval [CI] = 2.62 to 6.85) and younger age (age 18-24 years-OR = 4.57, 95% CI = 2.66 to 7.86; age 25-35 years-OR = 5.71, 95% CI = 3.71 to 8.81) were independently associated with hesitancy, to a greater degree than level of education (high school education or less-OR = 2.27, 95% CI = 1.23 to 4.19). Hesitant patients were significantly less likely to trust governmental sources of vaccine information than nonhesitant patients (39.6% vs. 78.9%, p < 0.001); less difference was noted in the domain of trust toward friends/family (51.1% vs. 61.0%, p = 0.004). Hesitant patients also reported perceived vaccine safety concerns and perceived insufficient research. CONCLUSIONS: Vaccine hesitancy is common among ED patients and more common among Black and younger patients, independent of education level. Hesitant patients report perceived safety concerns and low trust in government information sources but less so friends or family. This suggests that strategies to combat hesitancy may need tailoring to specific populations.

A rare life-threatening complication of acute mastoiditis: Case report and literature review.

Severe complications may not always present with "classic" signs and symptoms. In the setting of recent mastoiditis, complications including cerebral venous sinus thrombosis, skull base osteomyelitis, and retropharyngeal abscess should be considered, particularly with persistent or worsening symptoms. A broad differential can lead to prompt diagnosis and treatment, thereby reducing the likelihood of morbidity and mortality.

Incidence of Traumatic Delayed Intracranial Hemorrhage Among Patients Using Direct Oral Anticoagulants.

BACKGROUND: Emergency department visits due to head injury in the United States have increased significantly over the past decade, and parallel the increasing use of direct oral anticoagulants (DOACs). OBJECTIVE: We investigated the incidence of delayed intracranial hemorrhage (DICH) in patients with head injury who were taking DOACs. METHODS: We conducted a single-center retrospective study at a level II trauma center. All patients with head injury and using DOACs with an initial negative head computed tomography (HCT) scan from March 1, 2014 to December 31, 2017 were included. DICH was identified as a positive finding on repeat HCT performed within 24 h. Each case of DICH underwent blinded review by two additional neuroradiologists. Demographic data were collected; independent t-tests were used to compare group means and linear regression for variable correlations. RESULTS: Two hundred and eighty-seven patients with mean age of 80 years (interquartile range 14 years) met inclusion criteria. Repeat HCT was performed in 224 study participants (78%). Five (1.7%) resulted in DICH, three of which might have been present on initial HCT, with an incidence rate ranging from 0.7% to 1.7%. Only two initial HCTs were read as negative by all three neuroradiologists; 60% disagreed on the initial read. Independent t-test procedures showed an association between DICH and higher Injury Severity Score (ISS). CONCLUSIONS: We found a DICH incidence rate of 0.7-1.7%. ISS was statistically significant between the two groups. It is possible that in patients with a subjective estimation of low injury severity, a low mechanism of injury and reasonable outpatient follow-up, patients can be discharged home with standard head injury precautions and no repeat HCT, but further prospective studies are needed.

The Affordable Care Act and emergency department use by low acuity patients in a US hospital.

BACKGROUND: The Affordable Care Act (ACA) is one of the biggest healthcare reforms in US history. A key issue is the ACAs effect on low acuity, potentially primary care patients. This study evaluates the effect of the ACA on low acuity patients seen in the emergency department (ED). METHODS: This is an age-period-cohort analysis for a community hospital ED in Michigan, from 2009 to 2015. Patients were stratified by age, year seen, emergency severity index (ESI) and insurance status. Data were compared between before and after ACA along with descriptive statistics, Chi-square and Student t-tests. The primary outcome was the change in ED usage by low acuity. Patients > 65 were used as a temporal control. RESULTS: 305,350 ED visits were analyzed. ED visits with ESI 4/5 increased from 11.9% to 14.8%. Patients < 19 years increased from 25.5% to 34.3% (p = .0026). Ages 19-25 increased from 16.3% to 19.7% (p = 0.0515). Ages 26-64 increased from 11% to 14.9% (p = 0.0129). Ages > 65 increased from 5.1% to 6.5%. Patients < 65 showed a decreased uninsured rate from 12.30% to 6.28% (p < 0.0001). Comparatively, for age > 65: uninsured rate remained the same 0.46% to 0.49%. CONCLUSION: Low acuity ED visits increased with the ACA reform in conjunction with a more insured population.

Update on Neurological Manifestations of SARS-CoV-2.

Severe acute respiratory syndrome coronavirus 2, the source of COVID-19, causes numerous clinical findings including respiratory and gastrointestinal findings. Evidence is now growing for increasing neurological symptoms. This is thought to be from direct in-situ effects in the olfactory bulb caused by the virus. Angiotensin-converting enzyme 2 receptors likely serve as a key receptor for cell entry for most coronaviridae as they are present in multiple organ tissues in the body, notably neurons, and in type 2 alveolar cells in the lung. Hematogenous spread to the nervous system has been described, with viral transmission along neuronal synapses in a retrograde fashion. The penetration of the virus to the central nervous system (CNS) allows for the resulting intracranial cytokine storm, which can result in a myriad of CNS complications. There have been reported cases of associated cerebrovascular accidents with large vessel occlusions, cerebral venous sinus thrombosis, posterior reversible encephalopathy syndrome, meningoencephalitis, acute necrotizing encephalopathy, epilepsy, and myasthenia gravis. Peripheral nervous system effects such as hyposmia, hypogeusia, ophthalmoparesis, Guillain-Barré syndrome, and motor peripheral neuropathy have also been reported. In this review, we update the clinical manifestations of COVID-19 concentrating on the neurological associations that have been described, including broad ranges in both central and peripheral nervous systems.

Acute transverse myelitis associated with SARS-CoV-2: A Case-Report.

•The third case of acute transverse myelitis due to SARS-CoV-2 reported in the world.•Possible inflammatory complications affecting the myelin in spinal cord.•We must be vigilant of the critical neurological illnesses associated with COVID-19.

Comparison of admission rates among patients treated by male and female emergency physicians: a multicenter study.

BACKGROUND: No study to date has looked at the gender of emergency medicine (EM) physicians in the United States in relation to admission rates. This study seeks to investigate admission rates of adult patients treated by female vs male EM physicians, to identify whether a practice pattern bias exists. METHODS: This was a multicenter retrospective study of four community hospitals. POPULATION: All patient encounters between July 1, 2016 and June 30, 2017. OUTCOME: We compared multiple benchmarks, including admission rates, patient acuity, length of stay, return visits, patient age, and years of practice using descriptive statistics and Pearson Correlation Coefficients. RESULTS: 171,762 encounters by 71 EM physicians; 29 females, 42 males. Average admission rates: female 30.1%, male 28.0%, p = .188. Average encounters: female 2456, male 2394, p = 0.77. Acuity: female 149.3, male 146.9, p = .227. Average length of stay (minutes): female 294.4, male 277.4, p = .137. Average patient age: female 50.9, male 50.2, p = .457. Median time of encounter: female 12.8, male 12.7, p = .964. Years of practice: female 16.2, male 19.1, p = .274. Average return visits per one thousand: female 8.5, male 8.5, p = .864. Secondary analysis of Pearson Correlation Coefficient of Significance; admission rate and length of stay: female 0.53, p = .0026; male 0.76, p < .0001. Admission rate and acuity: female 0.56, p = .0012; male 0.76, p < .0001. Admission rate and patient age: female 0.54, p = 0.0018; male 0.50, p = 0.0003. CONCLUSION: No statistically significant difference exists between the admission rates of male and female emergency medicine physicians. The admission rate in both groups had the highest correlation with patients' age, acuity, and length of stay.

Rare anoxic brain injury sequela of delayed posthypoxic leukoencephalopathy due to recreational drug overdose with benzodiazepines.

A growth in recreational drug use will lead to a rise in delayed posthypoxic leukoencephalopathy cases. Physicians may inadvertently misdiagnose this rare condition as a primary psychiatric disorder by not maintaining a broad differential diagnosis.

Utility of INR For Prediction of Delayed Intracranial Hemorrhage Among Warfarin Users with Head Injury.

BACKGROUND: Incidence of delayed intracranial hemorrhage (DICH) in patients on warfarin has been controversial. No previous literature has reported the utility of international normalized ratio (INR) in predicting traumatic DICH. OBJECTIVES: Utilizing INR to risk stratify head trauma patients who may be managed without repeat imaging. METHODS: This was a retrospective study at a Level II trauma center. All patients on warfarin with head injuries from March 2014 to December 31, 2017 were included. Each patient underwent an initial head computed tomography scan (HCT) and subsequent repeat HCT 12 h after. Patients presenting > 12 h after head injury received only one HCT. Two blinded neuroradiologists reviewed each case of DICH. Statistical analysis evaluated Glasgow Coma Scale (GCS), Injury Severity Score (ISS), heart rate, systolic blood pressure (SBP), age, and platelet count. RESULTS: There were 395 patients who qualified for the protocol; 238 were female. Average age was 79 years. Seventy-seven percent of patients underwent repeat HCT. Five resulted in DICH (INR 2.6-3.0), three of which might have been present on initial HCT; incidence rate of 0.51-1.27%. One patient required neurosurgical intervention. Among 80 patients with INR < 2, no DICH was identified, resulting in high sensitivity, but with a wide confidence interval; sensitivity of 100% (95% confidence interval [CI] 47.8-100), specificity 21% (95% CI 16.6-28.9). Correlation of factors: ISS (p = 0.039), GCS (p = 0.978), HR (p = 0.601), SBP (p = 0.198), age (p = 0.014), and platelets (p = 0.281). CONCLUSION: No patient with INR < 2 suffered DICH, suggesting that warfarin users presenting with INR < 2 may be managed without repeat HCT. For INR > 2, patients age and injury severity can be used for shared decision-making to discharge home with standard head injury precautions and no repeat HCT.

Esophageal liposarcoma: Well-differentiated rhabdomyomatous type.

Rhabdomyomatous well-differentiated esophageal liposarcomas are extremely rare. As of August 2016, only one other such case has been reported in the English-language medical literature. Liposarcomas in general are one of the most common soft tissue neoplasms in adults, but the incidence of primary esophageal liposarcomas is exceptionally low. There have been only 42 reported cases of primary liposarcoma of the esophagus worldwide thus far. These malignancies are harbored within giant fibrovascular polyps, which slowly grow within the esophageal lumen causing obstructing symptoms. We hereby present the case of a 68-year-old male patient who came in with a 2-mo history of worsening intermittent dysphagia, persistent cough, and postprandial retrosternal pain. After an esophagogastroduodenoscopy, a computed tomographic scan, and a diagnostic endoscopy, complete endoscopic resection was performed of the 13 cm × 6 cm × 2.6 cm fibrovascular polyp. A literature review was done and results are presented herein.