Adverse Childhood Experiences (ACEs) in Unhoused Children Increase Odds of Psychiatric Illness, Physical Illness, and Psychiatric Admission.

Unhoused children and adolescents have high rates of adverse childhood experiences (ACEs). The objective of this study was to characterize a large cohort of unhoused children and investigate rates of psychiatric diagnoses, medical diagnoses, and utilization of emergency department (ED) resources depending on the presence of additional documented ACEs. A retrospective cohort of all unhoused children who presented to the ED of a large Midwestern health system from January 2014 to July 2019 were included. Unhoused status was determined by address field or ICD-10 code for homelessness (Z59.0). Demographics and ED visits were extracted from the electronic health record. Past medical history, ACEs, chief complaint (CC), length of stay (LOS), imaging, and labs were extracted by chart review. T-tests, chi square tests, and Fisher's exact tests were completed for each sub-analysis. Unhoused children with at least one additional ACE had higher odds of the following psychiatric disorders: depression (OR = 5.2, 95% CI = 3.4- 7.9), anxiety (OR = 3.4, 95% CI = 32.1-5.5), behavioral disorder (OR = 7.2, 95% CI = 35.1- 10.4), psychoses (OR = 6.0, 1.9-18.4), bipolar disorder (OR = 19.8, 95% CI = 34.6-84.9), suicidal ideation (OR = 8.0, 95% CI = 34.8-13.4), post-traumatic stress disorder (OR = 10.1, 95% CI = 35.4-18.6), and attention deficit hyperactive disorder (OR = 4.1, 3.0-5.7). Patients with additional documented ACEs were also more likely to have a prior psychiatric admission (p < 0.001). Unhoused children and adolescents with exposure to additional documented ACEs are more likely to have some serious psychiatric and medical diagnoses compared to other unhoused children.

Antemortem Health System Utilization in People Experiencing Homelessness Who Died in the Emergency Department.

People experiencing homelessness (PEH) have high rates of mortality, medical and psychiatric comorbidities, and emergency department utilization. In this study, a health system's emergency department encounters were evaluated to identify PEH who died in the emergency department. Patient demographics, medical history, prehospital and emergency department characteristics, and health care utilization patterns were collected. Descriptive statistics were calculated. We identified 48 PEH pronounced dead in the emergency department; mean age at death was 46.5. Forty-four (92%) decedents presented in cardiac arrest, 12 (25%) of which were substance use-related; 4 (8%) presented with trauma. Out of 44 patients presenting in cardiac arrest, (20.5%) had bystander cardiopulmonary resuscitation (CPR) performed before arrival of emergency medical services. In the year prior to death, 15 (32%) decedents had no documented health care utilization, while 16 (33%) had 10 or more emergency department/outpatient visits. Our study is the first to characterize PEH who died in the emergency department, analyzing the pre-hospital and in-hospital characteristics and antemortem health system utilization in this population. A sizeable proportion of deceased PEH had no health system contact in the 12 months prior to death, suggesting that those with high mortality risk may underutilize health services. Conversely, a similar proportion of decedents had extensive (more than 10) health system utilization in the year prior to death, representing possible opportunities to reduce mortality.

Treatment of Misophonia with Risperidone in a Patient with Autism Spectrum Disorder.

We report the case of a 32-year-old male with autism spectrum disorder (ASD) suffering from severe misophonia. After titrating risperidone to 2 mg twice a day, the patient reported a significant reduction in his symptoms and his Amsterdam misophonia scale-revised (AMISOS-R) score dropped by from 31 to 5. Upon discharge, the patient was noted to have decreased irritability and overall improved behavior and effect. This significant symptomatic improvement was likely not explained by inpatient admission alone or other simultaneous pharmacologic treatments, as the effect was seen during an isolated titration of risperidone with other treatments remaining constant. Although, unfortunately, follow-up findings indicated that the treatment was not curative for the patient, risperidone's potential for treating misophonia may warrant systematic investigation.

Shifting practice in pediatric prescription opioid use in the emergency department for fractures.

OBJECTIVES: Judicious opioid use is important for balancing patient comfort and safety. Although opioid use is well studied in adult populations, pediatric opioid prescription practices are less understood and there are very few guidelines regarding its usage. The purpose of this study was to investigate pediatric opioid prescription trends by emergency medicine physicians over the last ten years, including assessing proxies for the adequacy of pain control and risk of any opioid-related adverse events including overdose. METHODS: A retrospective analysis was performed of all patients age 0 to 18 who presented to an urban county hospital emergency department (ED) between 2007 and 2017 for acute fracture care. Data collected included age, opioids given in the ED, opioid prescriptions from the ED, adverse events, and secondary opioid prescriptions. Opioid prescription quantities were assessed in morphine equivalents (Meqs). RESULTS: Out of 4713 patients diagnosed with acute fracture, opioid prescriptions from the ED were given to 1772 patients (37.6%), with a mean quantity of 107.0 Meqs (SD = 69.1). Over the ten-year period studied, prescription rates declined from 54.8% in 2007 to 13.6% in 2017. Although 201 (4.3%) fracture patients had a second fracture-related ED visit, only 27 visits (0.57%) were for inadequate pain control, with no significant differences in year-to-year analysis. During the ten-year study period, there were zero opioid overdoses reported among pediatric fracture patients. CONCLUSIONS: A major shift has occurred in the last ten years, as emergency medicine physicians now favor non-opioid pain management regimens over opioids for the majority of pediatric fracture patients. There was no increase in the rate of inadequate pain control requiring a return to the ED, even as opioid prescription rates declined during the study period.