Sensitivity of a bedside reagent strip for the detection of spontaneous bacterial peritonitis in ED patients with ascites.

STUDY OBJECTIVE: To determine the sensitivity of a highly sensitive bedside leukocyte esterase reagent strip (RS) for detection of spontaneous bacterial peritonitis (SBP) in emergency department (ED) ascites patients undergoing paracentesis. METHODS: We conducted a prospective, observational cohort study of ED ascites patients undergoing paracentesis at two academic facilities. Two practitioners, blinded to each other's results, did a bedside RS analysis of the peritoneal fluid in each patient and documented the RS reading at 3-min according to manufacturer-specified colorimetric strip reading as either "negative", "trace", "small", or "large". The primary outcome measure was sensitivity of the RS strip for SBP (absolute neutrophil count ≥ 250 cells/mm3) at the "trace" threshold (positive equals trace or greater). RESULTS: There were 330 cases enrolled, with 635 fluid analyses performed. Of these, 40 fluid samples had SBP (6%). Bedside RS had a sensitivity, specificity, positive predictive value, and negative predictive value of 95% (95% CI 82%-99%), 48% (95% CI 44%-52%), 11% (95% CI 10%-11%), and 99% (95% CI 97%-99%) respectively at the "trace" threshold for the detection of SBP. CONCLUSION: Bedside use of the RS in ED ascites patients demonstrated high sensitivity for SBP. Given the wide confidence intervals, we cannot currently recommend it as a stand-alone test. We recommend further study with a larger number of SBP patients, potentially combining a negative RS result with low clinical suspicion to effectively rule out SBP without formal laboratory analysis.

Brief Intervention Among Mexican-Origin Young Adults in the Emergency Department at the USA-Mexico Border: Examining the Role of Patient's Preferred Language of Intervention in Predicting Drinking Outcomes.

AIMS: Determine if the language in which brief intervention (BI) is delivered influences drinking outcomes among Mexican-origin young adults in the emergency department when controlling for ethnic matching. SHORT SUMMARY: Aim of study was to determine if a patient's preferred language of intervention influences drinking outcomes among Mexican-origin young adults in the emergency department. Results indicate no significant differences in drinking outcomes among those who received BI in Spanish and BI in English. METHODS: This is a secondary data analysis on data from 310 patients randomized to receive a BI completed in Spanish (BI-S) or English (BI-E), with 3- and 12-month follow-up. Outcome measures of interest were drinking days per week, drinks per drinking day, maximum drinks in a day and negative consequences of drinking. RESULTS: There were no significant differences in drinking outcomes among those who received BI in Spanish and BI in English. CONCLUSIONS: Reduced drinking outcomes following BI among Mexican-origin young adults in the emergency department may not have been due to the language used to deliver intervention. Thus, our results provide evidence that language of intervention is not a crucial factor to achieve cultural congruence. In addition, our findings suggest that receiving the intervention is beneficial regardless of language, thus, facilitating real-world implementation.

Strengthening Primary Care Through Family Medicine Around the World Collaborating Toward Promising Practices.

BACKGROUND AND OBJECTIVES: There is a limited evidentiary base on the development of family medicine in different contexts and countries. The lack of evidence impedes our ability to compare and characterize family medicine models and identify areas of success that have led to the effective provision of care. This paper offers a comparative compilation and analysis of the development of family medicine training programs in seven countries: Brazil, Canada, Ethiopia, Haiti, Indonesia, Kenya, and Mali. METHODS: Using qualitative case studies, this paper examines the process of developing family medicine programs, including enabling strategies and barriers, and shared lessons. An appreciative inquiry framework and complex adaptive systems thinking inform our qualitative study. RESULTS: Committed partnerships, the contribution of champions, health policy, and adaptability were identified as key enablers in all seven case studies. The case studies further reveal that some enablers were more salient in certain contexts as compared to others, and that it is the interaction of enablers that is crucial for understanding how and why initiatives succeeded. The barriers that emerged across the seven case studies include: (1) resistance from other medical specialties, (2) lack of resources and capabilities, (3) difficulty in sustaining support of champions, and (4) challenges in brokering effective partnerships. CONCLUSIONS: A key insight from this study is that the implementation of family medicine is nonlinear, dynamic, and complex. The findings of this comparative analysis offer insights and strategies that can inform the design and development of family medicine programs elsewhere.

Preparing Mexican-Origin Community Health Advocates (Promotores) to Conduct SBIRT for Problem Drinking in the Emergency Room.

Community Health Advocates (CHAs), known as Promotores in Spanish-speaking communities, are an important resource for the mobilization, empowerment, and the delivery of health education messages in Hispanic/Latino communities. This article focuses on understanding cultural, didactic, and logistical aspects of preparing CHAs to become competent to perform a brief intervention and referral to treatment (SBIRT) in the emergency room (ER). The CHAs training emphasizes making connections with Mexican-origin young adults aged 18-30, and capitalizing on a teachable moment to effect change in alcohol consumption and negative outcomes associated with alcohol use. We outline a CHA recruitment, content/methods training, and the analysis of advantages and challenges presented by the delivery of an intervention by CHAs.

Differences by gender at twelve months in a brief intervention trial among Mexican-origin young adults in the emergency department.

In this study, we investigate the role of gender in prevalence and consequences of binge drinking and brief intervention outcomes among Mexican-origin young adults aged 18-30 years at the U.S.-Mexico border. We conducted a secondary analysis, stratified by gender, from a randomized controlled trial of a brief motivational intervention in a hospital emergency department. Intervention effects for males included reductions in drinking frequency, binge drinking, and alcohol-related consequences. For females the intervention was associated with reduction in drinking frequency and binge drinking but did not have a significant effect on alcohol-related consequences. Results suggest a new direction for tailoring interventions to gender.

Brief Intervention in the Emergency Department Among Mexican-Origin Young Adults at the US-Mexico Border: Outcomes of a Randomized Controlled Clinical Trial Using Promotores.

AIMS: A randomized controlled trial of brief intervention (BI), for drinking and related problems, using peer health promotion advocates (promotores), was conducted among at-risk and alcohol-dependent Mexican-origin young adult emergency department (ED) patients, aged 18-30. METHODS: Six hundred and ninety-eight patients were randomized to: screened only (n = 78), assessed (n = 310) and intervention (n = 310). Primary outcomes were at-risk drinking and Rapid Alcohol Problems Screen (RAPS4) scores. Secondary outcomes were drinking days per week, drinks per drinking day, maximum drinks in a day and negative consequences of drinking. RESULTS: At 3- and 12-month follow-up the intervention condition showed significantly lower values or trends on all outcome variables compared to the assessed condition, with the exception of the RAPS4 score; e.g. at-risk drinking days dropped from 2.9 to 1.7 at 3 months for the assessed condition and from 3.2 to 1.2 for the intervention condition. Using random effects modeling controlling for demographics and baseline values, the intervention condition showed significantly greater improvement in all consumption measures at 12 months, but not in the RAPS4 or negative consequences of drinking. Improvements in outcomes were significantly more evident for non-injured patients, those reporting drinking prior to the event, and those lower on risk taking disposition. CONCLUSIONS: At 12-month follow-up this study demonstrated significantly improved drinking outcomes for Mexican-origin young adults in the ED who received a BI delivered by promotores compared to those who did not. TRIAL REGISTER: ClinicalTrials.gov. CLINICAL TRIAL REGISTRATION NUMBER: NCT02056535.

Cultural adaptation of a brief motivational intervention for heavy drinking among Hispanics in a medical setting.

BACKGROUND: Hispanics, particularly men of Mexican origin, are more likely to engage in heavy drinking and experience alcohol-related problems, but less likely to obtain treatment for alcohol problems than non-Hispanic men. Our previous research indicates that heavy-drinking Hispanics who received a brief motivational intervention (BMI) were significantly more likely than Hispanics receiving standard care to reduce subsequent alcohol use. Among Hispanics who drink heavily the BMI effectively reduced alcohol use but did not impact alcohol-related problems or treatment utilization. We hypothesized that an adapted BMI that integrates cultural values and addresses acculturative stress among Hispanics would be more effective. METHODS/DESIGN: We describe here the protocol for the design and implementation of a randomized (approximately 300 patients per condition) controlled trial evaluating the comparative effectiveness of a culturally adapted (CA) BMI in contrast to a non-adapted BMI (NA-BMI) in a community hospital setting among men of Mexican origin. Study participants will include men who were hospitalized due to an alcohol related injury or screened positive for heavy drinking. By accounting for risk and protective factors of heavy drinking among Hispanics, we hypothesize that CA-BMI will significantly decrease alcohol use and alcohol problems, and increase help-seeking and treatment utilization. DISCUSSION: This is likely the first study to directly address alcohol related health disparities among non-treatment seeking men of Mexican origin by comparing the benefits of a CA-BMI to a NA-BMI. This study stands to not only inform interventions used in medical settings to reduce alcohol-related health disparities, but may also help reduce the public health burden of heavy alcohol use in the United States. TRIAL REGISTRATION: Trial registration clinicaltrials.gov identifier NCT02429401; Registration date: April 28, 2015.

Readiness to Change and to Accept Help and Drinking Outcomes in Young Adults of Mexican Origin.

OBJECTIVE: The purpose of this study was to assess whether readiness to change drinking (RCD) and readiness to accept help (RAH) improve short- and longer term drinking outcomes. METHOD: Data from a randomized controlled trial of screening and brief intervention (SBI) conducted in a U.S. emergency department at the U.S.-Mexico border are reported. A total of 620 at-risk and dependent Mexican-origin drinkers (56% male), ages 18-30, received either an assessment only or intervention (SBI). Drinking outcomes included drinking days per week, average and maximum drinks per drinking day, heavy drinking (5+ drinks) days per week, and negative consequences. Random effects longitudinal models predicted baseline, 3-month, and 12-month drinking outcomes from baseline RCD and RAH. Models tested if (a) outcomes were significantly reduced at follow-ups and (b) differential reduction occurred by RCD, RAH, and post-intervention changes in readiness among those receiving SBI. RESULTS: For both study groups, outcomes improved from baseline to each follow-up across RCD and RAH status. RCD was not associated with differential improvement in outcomes for either group. In the SBI group, those RAH reported larger reductions at 3 months in average and maximum quantity than those not RAH but did not differ from those not RAH at 12-month outcomes. Among the SBI group, changing from not ready to ready (RTC or RAH) post-intervention was not associated with greater reductions in drinking compared with remaining not ready or ready post-intervention. CONCLUSIONS: Baseline RCD is not associated with drinking outcomes. Baseline RAH may facilitate greater reductions in drinking for those receiving SBI and should be further examined as a possible mediator of SBI effects for young adults of Mexican origin.

Smoking Is Associated with Increased Risk of Binge Drinking in a Young Adult Hispanic Population at the US-Mexico Border.

BACKGROUND: This study examines factors related to general health and health behavior, including smoking, that may be associated with binge drinking, drinking "at risk," and potential for alcohol use disorder among young adults of Mexican ancestry. METHODS: A total of 2191 young adult emergency department (ED) patients (18-30 years) of Mexican ancestry in a public hospital proximate to the US-Mexico border completed health surveys while they were waiting to be treated, including questions on general health, drinking, smoking, and drug use. RESULTS: Thirty-seven percent of the study participants reported binge drinking, 38% were "at-risk" alcohol users (above National Institute on Alcohol Abuse and Alcoholism guidelines), and 22% were Rapid Alcohol Problem Screen (RAPS) positive (indicating potential for alcohol use disorder). Smoking was reported by 31%, marijuana use by 16%, and other drug use by 9%. Multiple variable models revealed that smoking was the strongest factor associated with binge drinking. Those who smoked were 3.1 (P < .0001) times more likely to binge drink. Other factors independently associated with binge drinking were age 22-25 years (odds ratio [OR] = 1.5, P = .003), male gender (OR = 1.5, P = .0001), and ED visit for injury (OR = 1.4, P = .007). CONCLUSIONS: There is a strong association of smoking and binge drinking. Study findings suggest that brief interventions designed to reduce preventable health risks for young Hispanics should include discussion of both binge drinking and smoking behaviors.

Cardiology electrocardiogram overreads rarely influence patient care outcome.

OBJECTIVE: The value of electrocardiogram (ECG) overreads of emergency department (ED) tracings have been questioned in the literature. This review was designed to assess the validity of this criticism. METHODS: In this university teaching hospital ED, following the normal quality assurance protocol, each abnormal ECG is reviewed the following day against the corresponding chart; and if the official reading from cardiology is discordant from the initial clinical one, the patient and/or their physician is contacted. If necessary, the patient is instructed to return to the ED or to their private physician's office. This study is a retrospective review of those ECG overreads for a 21-month period, as well as a summary of those patients who required follow-up care. RESULTS: There were 38,490 patients seen with ECGs performed during the study interval. Of these, 16,011 were discharged and 22,479 were admitted from a total patient volume of 117,407. Of those 16,011 patients discharged, follow-up was deemed necessary in 22 patients whose official readings were discordant from the interpretation of the original clinician. Three patients were lost to follow-up (no phone, no address). Review of the tracings and patient/physician follow-up of the 19 remaining patients resulted in a significant change of therapy in 2 patients (admission). The remainder of the abnormal tracings were deemed, after patient or private physician follow-up, to be not significant or to mandate no change in management. CONCLUSION: Official cardiology overreads seldom affect the clinical outcome of patient care delivered in the ED setting.

One-year outcomes of out-of-hospital administration of intravenous glucose, insulin, and potassium (GIK) in patients with suspected acute coronary syndromes (from the IMMEDIATE [Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care] Trial).

The Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency care Trial of very early intravenous glucose-insulin-potassium (GIK) for acute coronary syndromes (ACS) in out-of-hospital emergency medical service (EMS) settings showed 80% reduction in infarct size at 30 days, suggesting potential longer-term benefits. Here we report 1-year outcomes. Prespecified 1-year end points of this randomized, placebo-controlled, double-blind, effectiveness trial included all-cause mortality and composites including cardiac arrest, mortality, or hospitalization for heart failure (HF). Of 871 participants randomized to GIK versus placebo, death occurred within 1 year in 11.6% versus 13.5%, respectively (unadjusted hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.57 to 1.23, p = 0.36). The composite of cardiac arrest or 1-year mortality was 12.8% versus 17.0% (HR 0.71, 95% CI 0.50 to 1.02, p = 0.06). The composite of hospitalization for HF or mortality within 1 year was 17.2% versus 17.2% (HR 0.98, 95% CI 0.70 to 1.37, p = 0.92). The composite of mortality, cardiac arrest, or HF hospitalization within 1 year was 18.1% versus 20.4% (HR 0.85, 95% CI 0.62 to 1.16, p = 0.30). In patients presenting with suspected ST elevation myocardial infarction, HRs for 1-year mortality and the 3 composites were, respectively, 0.65 (95% CI 0.33 to 1.27, p = 0.21), 0.52 (95% CI 0.30 to 0.92, p = 0.03), 0.63 (95% CI 0.35 to 1.16, p = 0.14), and 0.51 (95% CI 0.30 to 0.87, p = 0.01). In patients with suspected acute coronary syndromes, serious end points generally were lower with GIK than placebo, but the differences were not statistically significant. However, in those with ST elevation myocardial infarction, the composites of cardiac arrest or 1-year mortality, and of cardiac arrest, mortality, or HF hospitalization within 1 year, were significantly reduced.

Fatal heat stroke associated with topiramate therapy.

A 40-year-old man with diabetes and seizure disorder was found at home unresponsive and "very hot to touch" by his father 40 minutes before emergency medical services arrival. His usual medications included topiramate, divalproex sodium, and rosiglitazone/metformin. Paramedics administered oxygen, intravenous fluids, and naloxone. They did not witness or report seizure activity. Upon emergency department arrival, the patient was unresponsive (Glasgow Coma Scale 3), hypotensive (94/50 mm Hg), and tachypneic (32 breaths per minute), with a heart rate of 60 beats per minute and elevated rectal temperature peaking at 43.2°C. His skin was hot and dry, without rash; physical examination was otherwise normal. Laboratory studies revealed severe metabolic acidosis with acute renal failure and rhabdomyolysis. In spite of sedation, intubation, and aggressive cooling measures, the patient had cardiac arrest and died approximately 2 hours after arrival. Serum topiramate and valproate concentrations were within therapeutic ranges at 8.8 µg/mL (therapeutic 2-12) and 97 µg/mL (therapeutic 50-100), respectively.

Project reduce: reducing alcohol and marijuana misuse: effects of a brief intervention in the emergency department.

STUDY OBJECTIVE: Brief interventions (BI) for alcohol misuse and recently for marijuana use for emergency department patients have demonstrated effectiveness. We report a 12-month outcome data of a randomized controlled trial of emergency department (ED) patients using a novel model of BI that addresses both alcohol and marijuana use. METHODS: ED research assistants recruited adult patients who admitted alcohol use in the last month, and marijuana use in the last year. In the ED, patients received an assessment of alcohol and marijuana use and were randomized to treatment (n=249) or standard care (n=266). Treatment consisted of two sessions of BI. At 3 and 12months, both groups had an assessment of alcohol and marijuana use and negative consequences of use. RESULTS: 515 patients were randomized. We completed a 12-month follow-up assessments on 83% of those randomized. Measures of binge drinking and conjoint marijuana and alcohol use significantly decreased for the treatment group compared to the standard care group. At 12-month binge alcohol use days per month in the treatment group were (M=0.72:95% CI=0.36-1.12) compared to standard care group (M=1.77:95% CI=1.19-1.57) Conjoint use days in the treatment group (M=1.25.1:95% CI=0.81-1.54) compared to standard care group (M=2.16:95% CI=1.56-2.86). No differences in negative consequences or injuries were seen between the treatment and standard care groups. CONCLUSIONS: BI for alcohol and marijuana decreased binge drinking and conjoint use in our treatment group. BI appears to offer a mechanism to reduce risky alcohol and marijuana use among ED patients but expected reductions in consequences of use such as injury were not found 12months after the ED visit.

DIAL: a randomised trial of a telephone brief intervention for alcohol.

BACKGROUND: Decreasing Injuries from ALcohol (DIAL) is a randomised control trial of a telephone brief intervention (BI) with injured emergency department (ED) patients with high-risk alcohol use. Here the authors examine 12-month outcomes of the intervention's effect on alcohol use, alcohol-related injuries and alcohol-related negative consequences. METHODS: ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, all participants received by telephone an assessment of their alcohol use, alcohol-related injuries, and alcohol-related negative consequences and then were randomised to treatment or standard care. Treatment consisted of two telephone sessions of BI focusing on risky alcohol use. Both groups were reassessed after 12 months. RESULTS: At 12 months, 249 (89%) participants completed follow-up assessments. After using a log transformation, the difference in alcohol-related injuries between baseline and 12-month follow-up was greater in the BI group than the standard care group (p=0.04); this is an effect size of Cohen's d=0.21. No difference between groups was found when comparing change in alcohol consumption and other alcohol-related negative consequences at 12 months. CONCLUSIONS: These findings suggest that a telephone BI with injured ED patients may decrease alcohol-related injuries. Identifying patients with risky alcohol use in the ED and then subsequently delivering the intervention by telephone after discharge has promise as a model for BI and deserves further study.

Enhanced motivational interviewing versus brief advice for adolescent smoking cessation: results from a randomized clinical trial.

BACKGROUND: Motivational interviewing (MI) is widely used for adolescent smoking cessation but empirical support for this approach is mixed. METHODS: Adolescent cigarette smokers 14-18 years old (N=162) were recruited from medical, school, and community settings and randomly assigned to enhanced MI or brief advice (BA) for smoking cessation. MI comprised an in-person individual session, a telephone booster session one week later, and a brief telephone-based parent intervention. BA consisted of standardized brief advice to quit smoking. Assessments occurred at baseline, post-treatment and at 1-, 3-, and 6-month follow ups. RESULTS: Biochemically-confirmed 7-day point prevalence abstinence rates were low (e.g., 4.5% for MI; 1.4% for BA at 1 month) and did not differ significantly by group at any follow up. Only those in MI reported significant decreases in cigarettes smoked per day (CPD) from baseline to 1 month. At 3 and 6 months, smokers in both groups reported significantly reduced CPD with no differences between groups. MI reduced perceived norms regarding peer and adult smoking rates, while BA had no effect on normative perceptions. No group differences emerged for self-reported motivation or self-efficacy to quit smoking. CONCLUSIONS: Findings support the efficacy of MI for addressing normative misperceptions regarding peer and adult smoking and for modestly reducing CPD in the short-term; however, these effects did not translate to greater smoking abstinence. MI may have more promise as a prelude to more intensive smoking intervention with adolescents than as a stand-alone intervention.

Out-of-hospital administration of intravenous glucose-insulin-potassium in patients with suspected acute coronary syndromes: the IMMEDIATE randomized controlled trial.

CONTEXT: Laboratory studies suggest that in the setting of cardiac ischemia, immediate intravenous glucose-insulin-potassium (GIK) reduces ischemia-related arrhythmias and myocardial injury. Clinical trials have not consistently shown these benefits, possibly due to delayed administration. OBJECTIVE: To test out-of hospital emergency medical service (EMS) administration of GIK in the first hours of suspected acute coronary syndromes (ACS). DESIGN, SETTING, AND PARTICIPANTS: Randomized, placebo-controlled, double-blind effectiveness trial in 13 US cities (36 EMS agencies), from December 2006 through July 31, 2011, in which paramedics, aided by electrocardiograph (ECG)-based decision support, randomized 911 (871 enrolled) patients (mean age, 63.6 years; 71.0% men) with high probability of ACS. INTERVENTION: Intravenous GIK solution (n = 411) or identical-appearing 5% glucose placebo (n = 460) administered by paramedics in the out-of-hospital setting and continued for 12 hours. MAIN OUTCOME MEASURES: The prespecified primary end point was progression of ACS to myocardial infarction (MI) within 24 hours, as assessed by biomarkers and ECG evidence. Prespecified secondary end points included survival at 30 days and a composite of prehospital or in-hospital cardiac arrest or in-hospital mortality, analyzed by intent-to-treat and by presentation with ST-segment elevation. RESULTS: There was no significant difference in the rate of progression to MI among patients who received GIK (n = 200; 48.7%) vs those who received placebo (n = 242; 52.6%) (odds ratio [OR], 0.88; 95% CI, 0.66-1.13; P = .28). Thirty-day mortality was 4.4% with GIK vs 6.1% with placebo (hazard ratio [HR], 0.72; 95% CI, 0.40-1.29; P = .27). The composite of cardiac arrest or in-hospital mortality occurred in 4.4% with GIK vs 8.7% with placebo (OR, 0.48; 95% CI, 0.27-0.85; P = .01). Among patients with ST-segment elevation (163 with GIK and 194 with placebo), progression to MI was 85.3% with GIK vs 88.7% with placebo (OR, 0.74; 95% CI, 0.40-1.38; P = .34); 30-day mortality was 4.9% with GIK vs 7.7% with placebo (HR, 0.63; 95% CI, 0.27-1.49; P = .29). The composite outcome of cardiac arrest or in-hospital mortality was 6.1% with GIK vs 14.4% with placebo (OR, 0.39; 95% CI, 0.18-0.82; P = .01). Serious adverse events occurred in 6.8% (n = 28) with GIK vs 8.9% (n = 41) with placebo (P = .26). CONCLUSIONS: Among patients with suspected ACS, out-of-hospital administration of intravenous GIK, compared with glucose placebo, did not reduce progression to MI. Compared with placebo, GIK administration was not associated with improvement in 30-day survival but was associated with lower rates of the composite outcome of cardiac arrest or in-hospital mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00091507.

Identifying subtypes of dual alcohol and marijuana users: a methodological approach using cluster analysis.

Alcohol is the most common psychoactive substance used with marijuana. However, little is known about the potential impact of different levels of use of both alcohol and marijuana and their influence on risky behaviors, injuries and psychosocial functioning. A systematic approach to identifying patterns of alcohol and marijuana use associated with increased risks has not yet been identified in the literature. We report on the secondary analysis of data collected from a RCT conducted in a busy urban emergency department. Cluster analysis was performed on the patterns of past 30-day alcohol and marijuana use in two random subsamples N1=210 and N2=217. Four distinct subtypes of those who use both alcohol and marijuana were identified: (1) Daily Marijuana and Weekly Alcohol users; (2) Weekly Alcohol and Weekly Marijuana users; (3) Daily Alcohol and Daily Marijuana users; and (4) Daily Alcohol, Weekly Marijuana users. The four subtypes were replicated in both subsamples and examination of the external validity using ANOVA to determine cluster differences on psychosocial and behavioral variables confirmed the theoretical relevance of different patterns of alcohol and marijuana use. There were significantly different psychosocial negative consequences and related risky behaviors among subtypes. We found that Daily Alcohol and Daily Marijuana users are at the highest risk to experience more negative consequences and engage in a broader spectrum of risky behaviors related to both substances, than the other three types of alcohol and marijuana users.

Beliefs and practices of pediatric emergency physicians and nurses regarding counseling alcohol-using adolescents: can counseling practice be predicted?

OBJECTIVES: The objectives of the study were to investigate the attitudes and practices of pediatric emergency department (PED) physicians (MDs), MD extenders (MD's assistants [PAs], nurse practitioners [NPs]), and nurses (RNs) regarding their counseling of alcohol-using adolescent PED patients and to determine which, if any, PED clinician characteristics predict current counseling practice. METHODS: An Internet-based survey of PED clinicians (MDs, PAs, NPs, and RNs) from 11 academic US PEDs was conducted. Respondents were asked about their counseling training, current counseling practices, confidence in their counseling skills, importance of counseling, attitudes and beliefs about counseling, and demographic information. Univariate and multivariate analyses were performed to determine the relationship between clinician characteristics and counseling practice. RESULTS: Counseling practice was strongly associated with one's profession; PED MDs/PAs/NPs reported significantly higher rates of counseling alcohol-using adolescents than PED RNs. These 2 groups differed significantly in terms of counseling training and experience. Counseling training and experience remained significant predictors of counseling practice, even after controlling for profession and other covariates. Both groups had similar views on the importance of counseling, confidence in their ability to counsel, and counseling substance-using adolescent PED patients. CONCLUSIONS: Pediatric ED MDs/PAs/NPs differ significantly from PED RNs in their counseling training, experience, and practice. These findings have important implications for the training and support necessary to successfully implement PED counseling. Specifically, formal training in counseling during professional schooling and garnering counseling experience after completing training may be critical factors in promoting PED counseling.

Brief Intervention for Emergency Department Patients with Alcohol Misuse: Implications for Current Practice.

This article reviews studies and current practices of brief motivational intervention in the emergency department and identifies factors related to the effectiveness of brief intervention. Studies of brief intervention in the emergency department have had mixed results with most studies showing improvements in both intervention and control groups. Most report brief intervention reducing alcohol's negative consequences without reducing consumption. Clinical practice is incorporating brief intervention as part of emergency treatment and further research is needed to determine the factors most responsible for the improvements noted in most studies.

Change plan as an active ingredient of brief motivational interventions for reducing negative consequences of drinking in hazardous drinking emergency-department patients.

OBJECTIVE: Few studies have examined the effects of brief motivational intervention components, such as change-plan completion, on treatment outcomes. This secondary analysis of an opportunistically recruited emergency-department sample of hazardous injured drinkers examines the potential predictive role of an alcohol-related change plan on treatment outcomes after accounting for pretreatment readiness. Written change plans were independently rated. METHOD: A mediational analysis framework tested directional hypotheses between pretreatment readiness, change plan, and treatment outcomes using linear regressions. The baseline total Drinker Inventory of Consequences (DrInC) score was covaried on 12-month DrInC total score, in all analyses. Participants who completed a brief motivational intervention and a change plan were included (N = 333). RESULTS: Pretreatment readiness was negatively associated with alcohol consequences at 12 months, (beta = -.09, t(254) = -2.07, p < .05, and good-quality change plans, (beta = .18, t(320) = 4.37, p < .001. With change plan and readiness in the same model, the relationship between readiness and treatment outcomes became nonsignificant, but change plan remained a significant predictor of treatment outcomes in the expected direction, beta = -.17, t(254) = -2.89, p < .01. Follow-up generalized linear modeling including an interaction term (change plan and pretreatment readiness) revealed that those with high readiness and a good-quality change plan versus those with low readiness and a poor-quality change plan had better-than-predicted outcomes for either readiness or change plan alone. CONCLUSIONS: Study findings suggest that the change plan in brief motivational intervention may be an active ingredient of treatment associated with better outcomes over and above the influence of pretreatment readiness.