Gender moderates the association between posttraumatic stress disorder and mutual intimate partner violence in an emergency department sample.

INTRODUCTION: Patients in emergency departments (EDs) constitute a diverse population with multiple health-related risk factors, many of which are associated with intimate partner violence (IPV). This paper examines the interaction effect of depression, posttraumatic stress disorder (PTSD), impulsivity, drug use, adverse childhood experiences (ACEs), at-risk drinking, and having a hazardous drinker partner with gender on mutual physical IPV in an urban ED sample. METHODS: Research assistants surveyed 1037 married, cohabiting, or partnered patients in face-to-face interviews (87% response rate) regarding IPV exposure, alcohol and drug use, psychological distress, ACEs, and other sociodemographic features. IPV was measured with the Revised Conflict Tactics Scale. Interaction effects were examined in multinomial and logistic models. RESULTS: Results showed a significant interaction of gender and PTSD (odds ratio [OR] 3.06, 95% CI 1.21-7.23, p < 0.05) for mutual IPV. Regarding main effects, there were also statistically significant positive associations between mutual physical IPV and at-risk drinking (OR 1.73, 95% CI 1.07-2.77, p < 0.05), having a hazardous drinker partner (OR 2.19, 95% CI 1.35-3.55, p < 0.01), illicit drug use (OR 2.09, 95% CI 1.18-3.71, p < 0.01), ACEs (OR 1.23, 95% CI 1.06-1.42, p < 0.01), days of cannabis use past in the 12 months (OR 1.003, 95% CI 1.002-1.005, p < 0.001), and impulsivity (OR 2.04, 95% CI 1.29-3.22, p < 0.01). CONCLUSIONS: IPV risk assessment in EDs will be more effective if implemented with attention to patients' gender and the presence of various and diverse other risk factors, especially PTSD.

Association of Cannabis Use and At-Risk Alcohol Use With Intimate Partner Violence in an Urban ED Sample.

INTRODUCTION: Urban ED patients have elevated rates of substance use and intimate partner violence. The purpose of this study is to describe the risk profiles for intimate partner violence among urban ED patients who report at-risk alcohol use only, cannabis use only, or both types of substance use. METHODS: Cross-sectional survey data were collected from study participants (N = 1037; 53% female; ages 18-50) following informed consent. We measured participants' past-year at-risk drinking (women/men who had 4+/5+ drinks in a day), cannabis use, psychosocial and demographic characteristics, and past-year physical intimate partner violence (assessed with the Revised Conflict Tactics Scale). We used bivariate analysis to assess whether rates of intimate partner violence perpetration and victimization differed by type of substance use behavior. Multivariate logistic regression models were estimated for each intimate partner violence outcome. All analyses were stratified by gender. RESULTS: Rates of intimate partner violence differed significantly by type of substance use behavior and were highest among those who reported both at-risk drinking and cannabis use. Multivariate analysis showed that women who reported at-risk drinking only, cannabis use only, or both types of substance use had increased odds for intimate partner violence perpetration and victimization compared with women who reported neither type of substance use. Men's at-risk drinking and cannabis use were not associated with elevated odds of intimate partner violence perpetration or victimization. DISCUSSION: Brief screening of patients' at-risk drinking and cannabis use behaviors may help identify those at greater risk for intimate partner violence and those in need of referral to treatment.

Interrelationships of Economic Stressors, Mental Health Problems, Substance Use, and Intimate Partner Violence among Hispanic Emergency Department Patients: The Role of Language-Based Acculturation.

We analyzed the interrelationships of economic stressors, mental health problems, substance use, and intimate partner violence (IPV) among a sample of Hispanic emergency department patients and probed if Spanish language preference, which may represent low acculturation and/or immigrant status, had a protective effect, in accordance with the Hispanic health paradox. Study participants (n = 520; 50% female; 71% Spanish speakers) provided cross-sectional survey data. Gender-stratified logistic regression models were estimated for mental health problems (PTSD, anxiety, depression), substance use (risky drinking, cannabis, illicit drug use), and IPV. Results showed that economic stressors were linked with mental health problems among men and women. Among men, PTSD was associated with greater odds of cannabis and illicit drug use. Men who used cannabis and illicit drugs were more likely to report IPV. Male Spanish speakers had lower odds of anxiety and cannabis use than English speakers. Female Spanish speakers had lower odds of substance use and IPV than English speakers. The protective effect of Spanish language preference on some mental health, substance use, and IPV outcomes was more pronounced among women. Future research should identify the mechanisms that underlie the protective effect of Spanish language preference and explore factors that contribute to the observed gender differences.

Drinking Context-Specific Dose-Response Models of Intimate Partner Violence Among an Urban Emergency Department Sample.

OBJECTIVE: This cross-sectional study evaluates the association between physical intimate partner violence (IPV) and frequencies of drinking and volume consumed in six different contexts among a sample of urban emergency department (ED) patients. METHOD: We obtained survey data from 1,037 married, cohabiting, or partnered patients (53% female; 50% Hispanic; 29% African American) at a Northern California safety-net hospital. Past-year physical IPV was measured with the Revised Conflict Tactics Scale. We asked patients about frequency of drinking and usual number of drinks consumed at bars, restaurants, homes of friends or relatives, own home, public places such as street corners or parking lots, and community centers or large events. Gender-stratified dose-response models were estimated for frequencies of IPV perpetration and victimization, with adjustment for sociodemographic and psychosocial factors, marijuana use, and spouse/partner problem drinking. RESULTS: None of the women's context-based frequency and volume measures were associated with frequency of IPV victimization. Women's volume of alcohol consumed at home was associated positively with frequency of their IPV perpetration (ß = .008, SE = .003, p < .01), and volume consumed in public places was associated negatively with this outcome (ß = -.023, SE = .010, p < .05). Among men, none of the context-based frequency and volume measures were associated with frequency of either IPV outcome. Spouse/partner's problem drinking was associated with each gender's IPV victimization, and with IPV perpetration by men. CONCLUSIONS: Frequency of drinking and volume consumed in specific contexts do not substantively contribute to frequency of IPV perpetration or victimization in this sample of urban ED patients.

Adverse childhood experiences are associated with at-risk drinking, cannabis and illicit drug use in females but not males: an Emergency Department study.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with adult substance use in the general population. Given pervasive health disparities among underserved populations, understanding how ACEs are associated with substance use among urban Emergency Department (ED) patients could help inform design of effective screening, brief interventions, and referral to treatment. OBJECTIVES: To estimate gender differences in prevalence of separate and cumulative ACEs among a sample of urban ED patients, and assess its association with at-risk drinking (4+/5+ drinks for females/males), cannabis, and illicit drug use. We hypothesized that the association between ACEs and each outcome would be stronger among females than males. METHODS: Cross-sectional survey data were obtained from 1,037 married/partnered ED patients (53% female) at a public safety-net hospital. Gender-stratified logistic regression models were estimated for each substance use outcome. RESULTS: One+ ACEs were reported by 53% of males and 60% of females. Females whose mother was a victim of domestic violence had greater odds of at-risk drinking compared to females who did not report this ACE (AOR = 1.72; 95% CI 1.03, 2.88). Females' cumulative ACEs were associated with cannabis use (OR = 2.26, 95% CI 1.06, 4.83) and illicit drug use (OR = 3.35; 95% CI 1.21, 9.30). Males' separate and cumulative ACEs were not associated with increased likelihood for any of the outcomes. CONCLUSION: ACEs are associated with greater odds of substance use among female than male ED patients. The prevalence of ACE exposure in this urban ED sample underscores the importance of ED staff providing trauma-informed care.

Co-Occurrence of Multiple Risk Factors and Intimate Partner Violence in an Urban Emergency Department.

INTRODUCTION: Urban emergency departments (ED) provide care to populations with multiple health-related and overlapping risk factors, many of which are associated with intimate partner violence (IPV). We examine the 12-month rate of physical IPV and its association with multiple joint risk factors in an urban ED. METHODS: Research assistants surveyed patients regarding IPV exposure, associated risk factors, and other sociodemographic features. The joint occurrence of seven risk factors was measured by a variable scored 0-7 with the following risk factors: depression; adverse childhood experiences; drug use; impulsivity; post-traumatic stress disorder; at-risk drinking; and partner's score on the Alcohol Use Disorders Identification Test. The survey (N = 1037) achieved an 87.5% participation rate. RESULTS: About 23% of the sample reported an IPV event in the prior 12 months. Logistic regression showed that IPV risk increased in a stepwise fashion with the number of present risk factors, as follows: one risk factor (adjusted odds ratio [AOR] [3.09]; 95% confidence interval [CI], 1.47-6.50; p<.01); two risk factors (AOR [6.26]; 95% CI, 3.04-12.87; p<.01); three risk factors (AOR = 9.44; 95% CI, 4.44-20.08; p<.001); four to seven risk factors (AOR [18.62]; 95% CI, 9.00-38.52; p<001). Ordered logistic regression showed that IPV severity increased in a similar way, as follows: one risk factor (AOR [3.17]; 95% CI, 1.39-7.20; p<.01); two risk factors (AOR [6.73]; 95% CI, 3.04-14.90; p<.001); three risk factors (AOR [10.36]; 95%CI, 4.52-23.76; p<.001); four to seven risk factors (AOR [20.61]; 95% CI, 9.11-46.64; p<001). CONCLUSION: Among patients in an urban ED, IPV likelihood and IPV severity increase with the number of reported risk factors. The best approach to identify IPV and avoid false negatives is, therefore, multi-risk assessment.

Problem Drinking and Marijuana Use as Risks for Unidirectional and Bidirectional Partner Violence.

Despite evidence that most who perpetrate intimate partner violence (IPV) also report victimization, little is known about bidirectional IPV among Emergency Department (ED) patients and its association with problem drinking and marijuana use. We conducted an observational, cross-sectional survey among low- and moderate-acuity patients at a Northern California safety-net ED. Physical IPV was measured with the Revised Conflict Tactics Scale (CTS2). We recorded patient's frequency of intoxication and marijuana use. Spouse/partner's problem drinking and marijuana use were measured dichotomously. Odds Ratios [ORs] and 95% confidence intervals [CIs] were estimated using multinomial logistic regression models of unidirectional and bidirectional IPV. Among 1,037 patients (53% female), perpetration only, victimization only, and bidirectional IPV were reported by 3.8%, 6.2%, and 13.3% of the sample, respectively. Frequency of intoxication was associated with perpetration (OR 1.50; 95% CI 1.18 to 1.92) and bidirectional IPV (OR=1.34; 95% CI 1.13 to 1.58). Days of marijuana use were associated with bidirectional IPV (OR=1.15; 95% CI 1.03 to 1.28). Patients whose partners were problem drinkers were at risk for victimization (OR=2.56; 95% CI=1.38, 4.76) and bidirectional IPV (OR=1.97; 95% CI 1.18, 3.27). Among patients who reported any past-year IPV, most experienced bidirectional aggression. ED staff should consider asking patients who are married, cohabiting, or in a dating relationship about their experience with past-year IPV and inquire about their substance use patterns and those of their romantic partner, to share information about potential linkages. Medical and recreational marijuana legalization trends underscore the importance of further research on IPV and marijuana.

Prevalence and Temporal Characteristics of Housing Needs in an Urban Emergency Department.

INTRODUCTION: Our objective was to determine the proportion of patients in our emergency department (ED) who are unhoused or marginally housed and when they typically present to the ED. METHODS: We surveyed patients in an urban, safety-net ED from June-August 2018, using a sampling strategy that met them at all times of day, every day of the week. Patients used two social needs screening tools with additional questions on housing during sampling shifts representing two full weeks. Housing status was determined using items validated for housing stability, including PRAPARE, the Accountable Health Communities Survey, and items from the United States Department of Health and Human Services. Propensity scores estimated differences among respondents and non-respondents. RESULTS: Of those surveyed, 35% (95% confidence interval [CI], 31-38) identified as homeless and 28% (95% CI, 25-31) as unstably housed. Respondents and non-respondents were similar by propensity score. The average cumulative number of homeless and unstably housed patients arriving per daily 8-hour window peaks at 7 AM, with 46% (95% CI, 29-64) of the daily aggregate of those reporting homelessness and 44% (95% CI, 24-64) with unstable housing presenting over the next eight hours. CONCLUSION: The ED represents a low-barrier contact point for reaching individuals experiencing housing challenges, who may interact rarely with other institutions. The current prevalence of homelessness and housing instability among urban ED patients may be substantially higher than reported in historical and national-level statistics. Housing services offered within normal business hours would reach a meaningful number of those who are unhoused or marginally housed.

Frequency of Intimate Partner Violence among an Urban Emergency Department Sample: A Multilevel Analysis.

Intimate partner violence (IPV) is a pervasive public health problem. Within the U.S., urban emergency department (ED) patients have elevated prevalence of IPV, substance use, and other social problems compared to those in the general household population. Using a social-ecological framework, this cross-sectional study analyzes the extent to which individual, household, and neighborhood factors are associated with the frequency of IPV among a socially disadvantaged sample of urban ED patients. Confidential survey interviews were conducted with 1037 married/partnered study participants (46% male; 50% Hispanic; 29% African American) at a public safety-net hospital. Gender-stratified multilevel Tobit regression models were estimated for frequency of past-year physical IPV (perpetration and victimization) and frequency of severe IPV. Approximately 23% of participants reported IPV. Among men and women, impulsivity, adverse childhood experiences, substance use, and their spouse/partner's hazardous drinking were associated with IPV frequency. Additionally, household food insufficiency, being fired or laid off from their job, perceived neighborhood disorder, and neighborhood demographic characteristics were associated with IPV frequency among women. Similar patterns were observed in models of severe IPV frequency. IPV prevention strategies implemented in urban ED settings should address the individual, household, and neighborhood risk factors that are linked with partner aggression among socially disadvantaged couples.

Gender Differences in Smoking Among an Urban Emergency Department Sample.

BACKGROUND: Urban emergency department (ED) patients have elevated smoking and substance use compared with the general population. We analyzed gender differences in smoking among an urban ED sample and assessed the contribution of substance use, demographic, and couple factors. METHODS: We conducted a secondary analysis of data obtained from a cross-sectional, observational survey (N = 1037 participants) on drinking, drug use, and intimate partner violence (IPV). Gender-specific logistic regression models for current (past 30-day) smoking and multinomial regression models for smoking intensity (light: ⩽5 cigarettes per day [CPD]; moderate: 6 to 10 CPD; heavier: >10 CPD) were estimated. RESULTS: Smoking prevalence was higher among men than women (35.5% vs 18.9%; P < .001). Substance use (frequency of intoxication, marijuana, amphetamine, and cocaine use), demographic (food insufficiency, unemployment), and couple-related factors (having a spouse/partner who smoked, IPV involvement, being in a same-gender couple) were differentially associated with current smoking and level of intensity among men and women. CONCLUSIONS: Emergency department staff should consider the impact of polysubstance use, food insufficiency, unemployment, and whether both partners in the couple smoke when screening patients for smoking and formulating cessation treatment plans. Women in same-gender relationships and those who have experienced IPV involvement may require additional referral.

Drinking and Intimate Partner Violence Severity Levels Among U.S. Ethnic Groups in an Urban Emergency Department.

BACKGROUND: Emergency departments (EDs) provide care to ethnically diverse populations with multiple health-related risk factors, many of which are associated with intimate partner violence (IPV). This paper examines ethnic-specific 12-month rates of physical IPV by severity and their association with drinking and other sociodemographic and personality correlates in an urban ED sample. METHODS: Research assistants surveyed patients at an urban ED regarding IPV exposure as well as patterns of alcohol and drug use, psychological distress, adverse childhood experiences (ACEs), and other sociodemographic features. RESULTS: The survey (N = 1,037) achieved an 87.5% participation rate. About 23% of the sample reported an IPV event in the past 12 months. Rates were higher (p < 0.001) among blacks (34%), whites (31%), and multiethnic (46%) respondents than those among Asians (13%) and Hispanics (15%). Modeled results showed that black respondents were more likely than Hispanics (reference) to report IPV (adjusted odds ratio [AOR] = 1.69, 95% confidence interval [CI] = 1.98-2.66, p < 0.05) and that respondents' partner drinking was associated with IPV (AOR = 1.85, 95% CI = 1.25-2.73, p < 0.01) but respondents' drinking was not. Use of illicit drugs, younger age, impulsivity, depression, partner problem drinking, ACEs, and food insufficiency were all positively associated with IPV. CONCLUSIONS: There was considerable variation in IPV rates across ethnic groups in the sample. The null results for the association between respondents' drinking and IPV was surprising and may stem from the relatively moderate levels of drinking in the sample. Results for ethnicity, showing blacks as more likely than Hispanics to report IPV, support prior literature.

Long-term Mortality in Pediatric Firearm Assault Survivors: A Multicenter, Retrospective, Comparative Cohort Study.

OBJECTIVES: The objective was to determine whether children surviving to hospital discharge after firearm assault (FA) and nonfirearm assault (NFA) are at increased risk of mortality relative to survivors of unintentional trauma (UT). Secondarily, the objective was to elucidate the factors associated with long-term mortality after pediatric trauma. METHODS: This was a multicenter, retrospective cohort study of pediatric patients aged 0 to 16 years who presented to the three trauma centers in San Francisco and Alameda counties, California, between January 2000 and December 2009 after 1) FA, 2) NFA, and 3) UT. The Social Security Death Master File and the California Department of Public Health Vital Statistics (2000-2014) were queried through December 31, 2014, to identify those who died after surviving their initial hospitalization and to delineate cause of death. Multivariate Cox proportional hazards regression was performed to determine associations between exposure to assault and long-term mortality. RESULTS: We analyzed 413 FA, 405 NFA, and 7,062 UT patients who survived their index hospital visit. A total of 75 deaths occurred, including 3.9, 3.2, and 0.7% of each cohort, respectively. Two-thirds of all long-term deaths were due to homicide. After multivariate adjustment, adolescent age, male sex, black race/ethnicity, and public insurance were independent risk factors for long-term mortality. FA (adjusted hazard ratio [AHR] = 1.8, 95% confidence interval [CI] = 0.82-4.0) and NFA (AHR = 1.9, 95% CI = 0.93-3.9) did not convey a statistically significant difference in risk of long-term mortality compared to UT. Being assaulted by any means (with or without a firearm), however, was an independent risk factor for long-term mortality in the full study population (AHR = 1.9, 95% CI = 1.01-3.4) and among adolescents (AHR = 1.9, 95% CI = 1.01-3.6). CONCLUSION: Children and adolescents who survive assault, including by firearm, have increased long-term mortality compared to those who survive unintentional, nonviolent trauma.

Material Needs of Emergency Department Patients: A Systematic Review.

BACKGROUND: Interest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States. METHODS: We followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles. RESULTS: Forty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs. CONCLUSIONS: Despite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.

D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study.

INTRODUCTION: Prehospital first responders historically have used an IV bolus of 50 mL of 50% dextrose solution (D50) for the treatment of hypoglycemia in the field. A local Emergency Medical Services (EMS) system recently approved a hypoglycemia treatment protocol of IV 10% dextrose solution (D10) due to occasional shortages and higher cost of D50. We use the experience of this EMS system to report the feasibility, safety, and efficacy of this approach. METHODS: Over the course of 104 weeks, paramedics treated 1,323 hypoglycemic patients with D10 and recorded patient demographics and clinical outcomes. Of these, 1,157 (87.5%) patients were treated with 100 mL of D10 initially upon EMS arrival, and full data on response to treatment was available on 871 (75%) of these 1,157. We captured the 871 patients' capillary glucose response to initial infusion of 100 mL of D10 and fit a linear regression line between elapsed time and difference between initial and repeat glucose values. We also explored the need for repeat glucose infusions as well as feasibility, and safety. RESULTS: The study cohort included 469 men and 402 women with a median age of 66. The median initial field blood glucose was 37 mg/dL, while the subsequent blood glucose had a median of 91 mg/dL. The median time to second glucose testing was eight minutes after beginning the 100mL D10 infusion. Of 871 patients, 200 (23.0%) required an additional dose of IV D10 solution due to persistent or recurrent hypoglycemia and seven (0.8%) patients required a third dose. There were no reported deaths or other adverse events related to D10 administration for hypoglycemia. Linear regression analysis of elapsed time and difference between initial and repeat glucose values showed near-zero correlation. CONCLUSIONS: The results of one local EMS system over a 104-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative to D50. D50 may also have theoretical risks including extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. Additionally, our data suggest that there may be little or no short-term decrease in blood glucose results after D10 administration.

Residency Applicant Preferences of Online Systems for Scheduling Interviews.

BACKGROUND: Residency applicants often have difficulty coordinating interviews with multiple programs. An online scheduling system might improve this process. OBJECTIVE: The authors sought to determine applicant mean time to schedule interviews and satisfaction using online scheduling compared with manual scheduling. METHODS: An electronic survey was sent to US graduates applying to any of 6 emergency medicine programs in the 2014-2015 application cycle. Of the participant programs, 3 used an online system and 3 did not. Applicants were asked to report estimated time to schedule with the online system compared to their average time using other methods, and to rate their satisfaction with the scheduling process. RESULTS: Of 1720 applicants to at least 1 of the 6 programs, 856 completed the survey (49.8%). Respondents reported spending less time scheduling interviews using the online system compared to other systems (median of 5 minutes [IQR 3-10] versus 60 minutes [IQR 15-240], respectively, P < .0001). In addition, applicants preferred using the online system (93.6% versus 1.4%, P < .0001.) Applicants were also more satisfied with the ease of scheduling their interviews using the online system (91.5% versus 11.0%, P < .0001) and felt that the online system aided them in coordinating travel arrangements (74.7% versus 41.5%, P < .01.). CONCLUSIONS: An online interview scheduling system is associated with time savings for applicants as well as higher satisfaction among applicants, both in ease of scheduling and in coordinating travel arrangements. The results likely are generalizable to other medical and surgical specialties.

How Prevalent Are Potentially Illegal Questions During Residency Interviews? A Follow-up Study of Applicants to All Specialties in the National Resident Matching Program.

PURPOSE: To describe the prevalence and effects on applicants of being asked potentially illegal questions during the residency interview process by surveying all residency applicants to all specialties. METHOD: The authors surveyed all applicants from U.S. medical schools to residency programs in all specialties in 2012-2013. The survey included questions about the prevalence of potentially illegal questions, applicants' level of comfort with such questions, and whether such questions affected how applicants ranked programs. Descriptive statistics, tests of proportions, t tests, and logistic regression modeling were used to analyze the data. RESULTS: Of 21,457 eligible applicants, 10,976 (51.1%) responded to the survey. Overall, 65.9% (7,219/10,967) reported receiving at least one potentially illegal question. More female respondents reported being asked questions about gender (513/5,357 [9.6%] vs. 148/5,098 [2.9%]), marital status (2,895/5,283 [54.8%] vs. 2,592/4,990 [51.9%]), or plans for having children (889/5,241 [17.0%] vs. 521/4,931 [10.6%]) than male respondents (P < .001). Those in surgical specialties were more likely to have received a potentially illegal question than those in nonsurgical specialties (1,908/2,330 [81.9%] vs. 5,311/8,281 [64.1%]). Questions regarding their commitment to the program were reported by 15.5% (1,608/10,378) of respondents. Such potentially illegal questions negatively affected how respondents ranked programs. CONCLUSIONS: Two-thirds of applicants reported being asked potentially illegal questions. More women than men reported receiving questions about marital status or family planning. Potentially illegal questions negatively influence how applicants perceive and rank programs. A formal interview code of conduct or interviewer training could help to address these issues.