Total CroFab and Anavip Antivenom Vial Administration in US Rattlesnake Envenomations: 2019-2021.

INTRODUCTION: In 2018, Anavip became available for the treatment of rattlesnake envenomations in the USA. No comparisons between the treatment characteristics of patients have been made since Anavip and CroFab have both been widely available. The objective of this study was to compare the number of antivenom vials administered of CroFab and Anavip during the treatment of rattlesnake envenomations in the USA. METHODS: This was a secondary analysis of rattlesnake envenomations utilizing the North American Snakebite Registry (NASBR) from 2019 through 2021. Frequencies and proportions were used to summarize demographics and baseline clinical characteristics. The primary outcome was total antivenom vials administered during treatment. Secondary outcomes included the number antivenom administration events, total treatment time, and hospital length of stay. RESULTS: Two hundred ninety-one rattlesnake envenomations were analyzed; most occurred in the Western USA (n = 279, 96 %). One hundred one patients (35%) received only CroFab, 110 (38%) received Anavip only, and 80 (27%) received both products. The median number of vials used was 10 for CroFab, 18 for Anavip, and 20 for both antivenoms. More than one antivenom administration was necessary in thirty-nine (39%) patients that received only CroFab and 76 (69%) patients that received Anavip only. The median total treatment time was 5.5 hours for CroFab, 6.5 for Anavip, and 15.5 hours when both antivenoms were administered. All antivenom groups had a median hospital length of stay of 2 days. CONCLUSIONS: Rattlesnake envenomated patients in the Western USA treated with CroFab had fewer antivenom vials and fewer antivenom administrations compared to patients treated with Anavip.

Use of an Agitation Measure to Screen for Suicide and Self-Harm Risk Among Emergency Department Patients.

BACKGROUND: Suicidality alone is insensitive to suicide risk among emergency department (ED) patients. OBJECTIVE: We describe the performance of adding an objective assessment of agitation to a suicide screening instrument for predicting suicide and self-harm after an ED encounter. METHODS: We tested the performance of a novel screener combining the presence of suicidality or agitation for predicting suicide within 90 days or a repeat ED visit for self-harm within 30 days using retrospective data from all patients seen in an urban safety net ED over 27 months. Patients were assessed for suicidality using the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener and for agitation using either the Behavioral Activity Rating Scale or Richmond Agitation Sedation Scale. We hypothesized that a screener based on the presence of either suicidality or agitation would be more sensitive to suicide risk than the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone. The screener's performance is described, and multivariable regression evaluates the correlations between screening and outcomes. RESULTS: The sample comprised 16,467 patients seen in the ED who had available suicide screening and agitation data. Thirteen patients (0.08%) died by suicide within 90 days after ED discharge. The sensitivity and specificity of the screener combining suicidality and agitation for predicting suicide was 0.69 (95% confidence interval, 0.44-0.94) and 0.74 (0.44-0.94), respectively. The sensitivity and specificity for agitation combined with positive suicide screening for self-harm within 30 days were 0.95 (0.89-1.00) and 0.73 (0.73-0.74). For both outcomes, augmenting the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener with a measure of agitation improved both sensitivity and overall performance compared to historical performance of the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone. CONCLUSIONS: Combining a brief objective measure of agitation with a common suicide screening instrument improved sensitivity and predictive performance for suicide and self-harm risk after ED discharge. These findings speak to the importance of assessing agitation not only for imminent safety risk during the patient encounter but also for reducing the likelihood of future adverse events. This work can improve the detection and management of suicide risk in emergency settings.

Suicide and Self-Harm Outcomes Among Psychiatric Emergency Service Patients Diagnosed As Malingering.

BACKGROUND: Malingering is a common and challenging clinical presentation in emergency departments (EDs). OBJECTIVE: This study describes characteristics and outcomes among patients diagnosed as malingering in a psychiatric emergency service. METHODS: Index psychiatric ED encounters were identified for all adult patients seen during a 27-month period. Mortality data were obtained for patients from the state public health authority, and repeat ED visits for self-harm were obtained from the state hospital association. Patients with a diagnosis of malingering were compared with those without a malingering diagnosis using correlative statistics and multivariable analyses. RESULTS: Of 4710 encounters analyzed, 236 (5%) had a malingering diagnosis. No patients diagnosed as malingering died of suicide within 365 days of discharge, compared with 16 (0.4%) nonmalingering patients. Self-harm outcomes were available for 2689 encounters; 129 (5%) had a malingering diagnosis. Malingering was significantly associated with a repeat ED visit for self-harm within 365 days in multivariable analyses (adjusted odds ratio 2.52; 95% confidence interval 1.35-4.70); p < 0.01). CONCLUSIONS: No psychiatric emergency service patients diagnosed as malingering died by suicide after discharge. New clinical approaches must balance malingering patients' apparent low suicide risk with their other substantial comorbidities and risk for self-harm.

Suicidal ideation is insensitive to suicide risk after emergency department discharge: Performance characteristics of the Columbia-Suicide Severity Rating Scale Screener.

OBJECTIVES: We describe the Columbia-Suicide Severity Rating Scale (C-SSRS)-Clinical Practice Screener's ability to predict suicide and emergency department (ED) visits for self-harm in the year following an ED encounter. METHODS: Screening data from adult patients' first ED encounter during a 27-month study period were analyzed. Patients were excluded if they died during the encounter or left without being identified. The outcomes were suicide as reported by the state health department and a recurrent ED visit for suicide attempt or self-harm reported by the state hospital association. Multivariable regression examined the screener's correlation with these outcomes. RESULTS: Among 92,643 patients analyzed, eleven (0.01%) patients died by suicide within a month after ED visit. The screener's sensitivity and specificity for suicide by 30 days were 0.18 (95% confidence interval [CI] = 0.00 to 0.41) and 0.99 (95% CI = 0.99 to 0.99). Sensitivity and specificity were better for predicting self-harm by 30 days: 0.53 (95% CI = 0.42 to 0.64) and 0.97 (95% CI = 0.97 to 0.97), respectively. Multivariable regression demonstrated that screening risk remained associated with both suicide and self-harm outcomes in the presence of covariates. Suicide risk was not mitigated by hospitalization or psychiatric intervention in the ED. CONCLUSIONS: The C-SSRS screener is insensitive to suicide risk after ED discharge. Most patients who died by suicide screened negative and did not receive psychiatric services in the ED. Moreover, most patients with suicidal ideation died by causes other than suicide. The screener was more sensitive for predicting nonfatal self-harm and may inform a comprehensive risk assessment. These results compel us to reimagine the provision of emergency psychiatric services.