Emergency Department Use in the Perinatal Period: An Opportunity for Early Intervention.

STUDY OBJECTIVE: We characterize emergency department (ED) utilization among perinatal women and identify differences in risk factors and outcomes between women who use versus do not use the ED during the perinatal period. METHODS: This is a retrospective cross-sectional study comparing patients who used the ED versus did not use the ED during the perinatal period. Patient data were collected from medical chart review and postpartum interviews. RESULTS: Of the 678 participants, 218 (33%) had at least 1 perinatal ED visit. Women who used the ED were more likely than those who did not to be adolescent (relative risk [RR] 2.23; 95% confidence interval [CI] 1.38 to 3.63), of minority race (RR 1.94; 95% CI 1.46 to 2.57), and Medicaid insured (RR 2.14; 95% CI 1.71 to 2.67). They were more likely to smoke prenatally (RR 3.42; 95% CI 2.34 to 4.99), to use recreational drugs prenatally (RR 3.53; 95% CI 1.78 to 7.03), and to have experienced domestic abuse (RR 1.78; 95% CI 1.12 to 2.83). They were more likely to have delayed entry to prenatal care (RR 2.01; 95% CI 1.46 to 2.77) and to experience postpartum depression (RR 2.97; 95% CI 1.90 to 4.64). Their infants were nearly twice as likely to be born prematurely (RR 1.92; 95% CI 1.07 to 3.47). CONCLUSION: Results highlight that pregnant patients using the ED are a high-risk, vulnerable population. Routine ED screening and linkage of this vulnerable population to early prenatal care and psychosocial interventions should be considered as a public health strategy worth investigating.

Intimate Partner Violence Associated with Postpartum Depression, Regardless of Socioeconomic Status.

Objective This study examined whether socioeconomic status moderated the association between intimate partner violence (IPV) and postpartum depression among a community-based sample of women. Defining the role of poverty in the risk of postpartum depression for IPV victims enables prioritization of health promotion efforts to maximize the effectiveness of existing maternal-infant resources. Methods This cross-sectional telephone-survey study interviewed 301 postpartum women 2 months after delivery, screening them for IPV and depression [using Edinburgh Postnatal Depression Scale (EPDS)]. Socioeconomic status was defined by insurance (Medicaid-paid-delivery or not). This analysis controlled for the following covariates, collected through interview and medical-record review: demographics, obstetric history, prenatal health and additional psychosocial risk factors. After adjusting for significant covariates, multiple linear regression was conducted to test whether socioeconomic status confounded or moderated IPV's relationship with EPDS-score. Results Ten percent of participants screened positive for postpartum depression, 21.3 % screened positive for current or previous adult emotional or physical abuse by a partner, and 32.2 % met poverty criteria. IPV and poverty were positively associated with each other (χ(2) (1) = 11.76, p < .001) and with EPDS score (IPV: beta 3.2 (CI 2.0, 4.5) p < .001, poverty: beta 1.3 (CI 0.2, 2.4) p = .017). In the multiple linear regression, IPV remained significantly associated, but poverty did not (IPV: adjusted beta 3.1 (CI 1.8, 4.3) p < .001, poverty: adjusted beta 0.8 (CI -0.3, 1.9) p = .141), and no statistically significant interaction between IPV and poverty was found. Conclusions Study findings illustrated that IPV was strongly associated with postpartum depression, outweighing the influence of socioeconomic status upon depression for postpartum women.

Reducing HIV-related risk behaviors among injection drug users in residential detoxification.

This study of 632 drug injectors enrolled in eight residential detoxification centers within the National Drug Abuse Treatment Clinical Trials Network tested three interventions to reduce drug and sex risk behaviors. Participants were randomized to: (a) a two-session, HIV/HCV counseling and education (C&E) model added to treatment as usual (TAU), (b) a one-session, therapeutic alliance (TA) intervention conducted by outpatient counselors to facilitate treatment entry plus TAU, or (c) TAU. Significant reductions in drug and sex risk behaviors occurred for all three conditions over a 6-month follow-up period. C&E participants reported significantly greater rates of attending an HIV testing appointment, but this was not associated with better risk reduction outcomes. Reporting treatment participation within 2 months after detoxification and self-efficacy to practice safer injection behavior predicted reductions in injection risk behaviors. Findings indicate that participation in detoxification was followed by significant decreases in drug injection and risk behaviors for up to 6-months; interventions added to standard treatment offered no improvement in risk behavior outcomes.

Improving the transition from residential to outpatient addiction treatment: gender differences in response to supportive telephone calls.

Substance use relapse rates are often high in the first months after discharge from inpatient substance abuse treatment, and patient adherence to aftercare plans is often low. Four residential addiction treatment centers participated in a feasibility study designed to estimate the efficacy of a post-discharge telephone intervention intended to encourage compliance with aftercare. A total of 282 participants (100 women, 182 men) with substance use disorders were included in this secondary analysis. The findings revealed that women were more likely than men to attend aftercare. This "gender effect" persisted after adjustment for a number of potential mediators.

Telephone enhancement of long-term engagement (TELE) in continuing care for substance abuse treatment: a NIDA clinical trials network (CTN) study.

The TELE study examined the feasibility and potential efficacy of phone calls to patients after discharge from short- term inpatient and residential substance abuse treatment programs to encourage compliance with continuing care plans. After review of their continuing care plans, 339 patients from four programs were randomized either to receive calls or to have no planned contact. Ninety-two percent of patients randomized to receive calls received at least one call. No difference was found between groups in self-reported attendance at one or more outpatient counseling sessions after discharge (p = .89). When program records of all participants were examined, those receiving calls had a greater likelihood of documented attendance (48%) than those not called (37%). Results were not statistically significant (p < .003) because of the Hochberg correction for multiple tests. While the phone calls were feasible, the lack of clear evidence of efficacy of the calls suggests the need for further investigation of the role of telephone intervention to encourage compliance and improve outcomes.

Naltrexone renders one-session exposure therapy less effective: a controlled pilot study.

In vivo exposure has become the gold standard treatment for specific phobia. The endogenous opioid system is one mechanism proposed to explain why exposure provides such quick and effective treatment for specific phobia. The effect of naltrexone on fear and avoidance behavior was investigated among 15 specific phobia participants who received exposure treatment. Participants were randomly assigned to receive naltrexone, placebo, or no drug prior to attending one-session exposure treatment. Mixed effects regression results revealed that across time, the naltrexone group tolerated significantly less time in the room with the feared animal (Behavioral Avoidance Index) as compared to the placebo and no drug groups. Phobic individuals assigned to the naltrexone group had significantly higher fear ratings across time in comparison to the placebo group. Results provide support for the endogenous opioid system as a potential underlying biological mechanism associated with behavioral changes during in vivo exposure.

Phenobarbital-induced bullous lesions in a non-comatose patient.

The occurrence of dermatologic bullous lesions is well documented after barbiturate-induced intoxication. However, this rare clinicopathological entity is only reported in the setting of a coma or lethal toxicity. This case report presents a case of a noncomatose, nonimmobilized patient who developed systemic bullous lesions after an acute ingestion of oral phenobarbital. This case illustrates that bullous lesions can occur as a result of nontoxic phenobarbital doses, in the setting of subtherapeutic barbiturate blood levels. All previous case reports suggest phenobarbital produces either systemic bullae only after coma-inducing doses or a localized bullous reaction after a high-dose intravenous injection. This case challenges this previously held association. Although the exact mechanism of the bullous lesions remains unknown, the clinical course of the lesions is self-limiting and does not require additional care beyond the treatment of a superficial burn. Resolution of the bullae occured within two weeks. Since phenobarbital continues to be prescribed orally, physicians should recognize bullous lesions as a potential adverse dermatological reaction from non-lethal oral doses of phenobarbital.

Genetic and nongenetic factors influencing substance use by adolescents.

Substance use by adolescents can lead to mortality, physical and social morbidity, and a brain disorder called substance dependence if allowed to progress to chronic, repetitive self-administration. Substance abuse and dependence can begin in adolescence or adulthood, but many of the attitudes and behaviors that affect risk become established during adolescence. Genetic risk factors have been identified for at least two distinct disorders and more are under active study to determine the cause and pathophysiology of addictive disorders. Although much remains to be done, a complex interplay of numerous genetic and environmental risk factors clearly is involved. An understanding of the most important environmental risk factors has led to effective primary prevention approaches; knowledge of the genetic risk factors and neuropharmacology of drugs of abuse in the brain is beginning to influence secondary prevention efforts and treatment, including better medications for addictive disorders. A large proportion of adolescents carry a genetic vulnerability that can be expressed when they accept peer and societal influences that promote experimentation with substances of abuse. At that point, the genetic factors take over, maintaining the drug self-administration pattern. Decay of social status results from association with drug-using peers and shifts in priorities supportive of drug use rather than education and productivity. More research into the genetic risk factors and applications of current knowledge to treatment is needed.