Publications by authors named "Michael P Wilson"

89 Publications

Association of the COVID-19 pandemic and dying at home due to ischemic heart disease.

Prev Med 2021 Sep 29;153:106818. Epub 2021 Sep 29.

Arkansas Department of Health, Little Rock, AR 72205, United States of America; Pediatric Infectious Diseases Section, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR 72205, United States of America.

The coronavirus disease 2019 (COVID-19) pandemic has been associated with a declining volume of patients seen in the emergency department. Despite the need for seeking urgent care for conditions such as myocardial infarction, many people may not seek treatment. This study seeks to measure associations between the COVID-19 pandemic and location of death among individuals who died from ischemic heart disease (IHD). Data obtained from death certificates from the Arkansas Department of Health was used to conduct a difference-in-difference analysis to assess whether decedents of IHD were more likely to die at home during the pandemic (March 2020 through September 2020). The analysis compared location of death for decedents of IHD pre and during the pandemic to location of death for decedents from non-natural causes. Before the pandemic, 50.0% of decedents of IHD died at home compared to 57.9% dying at home during (through September 2020) the pandemic study period (p < .001). There was no difference in the proportion of decedents who died at home from non-natural causes before and during the pandemic study period (55.8% vs. 53.5%; p = .21). After controlling for confounders, there was a 48% increase in the odds of dying at home from IHD during the pandemic study period (p < .001) relative to the change in dying at home due to non-natural causes. During the study period, there was an increase in the proportion of decedents who died at home due to IHD. Despite the ongoing pandemic, practitioners should emphasize the need to seek urgent care during an emergency.
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http://dx.doi.org/10.1016/j.ypmed.2021.106818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8480010PMC
September 2021

Association of the COVID-19 pandemic and dying at home due to ischemic heart disease.

Prev Med 2021 Sep 29;153:106818. Epub 2021 Sep 29.

Arkansas Department of Health, Little Rock, AR 72205, United States of America; Pediatric Infectious Diseases Section, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR 72205, United States of America.

The coronavirus disease 2019 (COVID-19) pandemic has been associated with a declining volume of patients seen in the emergency department. Despite the need for seeking urgent care for conditions such as myocardial infarction, many people may not seek treatment. This study seeks to measure associations between the COVID-19 pandemic and location of death among individuals who died from ischemic heart disease (IHD). Data obtained from death certificates from the Arkansas Department of Health was used to conduct a difference-in-difference analysis to assess whether decedents of IHD were more likely to die at home during the pandemic (March 2020 through September 2020). The analysis compared location of death for decedents of IHD pre and during the pandemic to location of death for decedents from non-natural causes. Before the pandemic, 50.0% of decedents of IHD died at home compared to 57.9% dying at home during (through September 2020) the pandemic study period (p < .001). There was no difference in the proportion of decedents who died at home from non-natural causes before and during the pandemic study period (55.8% vs. 53.5%; p = .21). After controlling for confounders, there was a 48% increase in the odds of dying at home from IHD during the pandemic study period (p < .001) relative to the change in dying at home due to non-natural causes. During the study period, there was an increase in the proportion of decedents who died at home due to IHD. Despite the ongoing pandemic, practitioners should emphasize the need to seek urgent care during an emergency.
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http://dx.doi.org/10.1016/j.ypmed.2021.106818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8480010PMC
September 2021

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department.

Ann Emerg Med 2021 09 23;78(3):434-442. Epub 2021 Jun 23.

Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.

The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January 2021.
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http://dx.doi.org/10.1016/j.annemergmed.2021.04.023DOI Listing
September 2021

In reply: Bias risk in systematic reviews.

Am J Emerg Med 2021 07 31;45:600-601. Epub 2020 Dec 31.

Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) Lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2020.12.035DOI Listing
July 2021

Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation).

J Am Coll Emerg Physicians Open 2020 Oct 3;1(5):898-907. Epub 2020 Jul 3.

University of Arkansas for Medical Sciences Department of Emergency Medicine Little Rock Arkansas USA.

Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life-threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de-escalation as a first-line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.
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http://dx.doi.org/10.1002/emp2.12138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7593430PMC
October 2020

Intramuscular medication for treatment of agitation in the emergency department: A systematic review of controlled trials.

Am J Emerg Med 2021 08 9;46:193-199. Epub 2020 Jul 9.

Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America. Electronic address:

Background: Severely agitated patients in the emergency department (ED) are often sedated with intramuscularly-administered medications. The evidence base underlying particular medication choices is surprisingly sparse, as existing reviews either have methodological limitations or have included data collected outside of emergent settings.

Objectives: The objective of this review was to examine all controlled trials in emergent settings that have used standardized scales to measure the effectiveness of intramuscular medication for the treatment of acute agitation.

Methods: This review was registered in Prospero as CRD42018105745. PubMed, International Pharmaceutical Abstracts, Web of Science, PsycINFO, and clinicaltrials.gov were searched for prospective controlled trials investigating intramuscular antipsychotics for agitation. Articles were assessed for bias across five domains using the revised Cochrane Risk of Bias Tool.

Results: Eight studies were eligible for inclusion in the systematic review, none of which had a low risk of bias. Five studies had a moderate risk of bias with heterogenous designs, populations, and treatments. These studies seemed to suggest that second generation antipsychotics (SGAs) likely reduce agitation as effectively as first generation antipsychotics (FGAs) plus an adjunctive medication with similar or lower risk of side effects.

Conclusions: Existing trials on the use of intramuscular antipsychotics in the ED/psychiatric ED setting were small, heterogenous, and at a moderate or high risk of bias. Given the clinical importance of this topic, further prospective investigations are desperately needed but are currently unfeasible under Food and Drug Administration Exception From Informed Consent regulations.
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http://dx.doi.org/10.1016/j.ajem.2020.07.013DOI Listing
August 2021

Management of Agitation During the COVID-19 Pandemic.

West J Emerg Med 2020 May 22;21(4):795-800. Epub 2020 May 22.

University of Pittsburgh School of Law and School of Medicine, Department of Psychiatry, Pittsburgh, Pennsylvania.

The coronavirus disease 2019 (COVID-19) pandemic caused by the coronavirus SARS-CoV-2 has radically altered delivery of care in emergency settings. Unprecedented hardship due to ongoing fears of exposure and threats to personal safety, along with societal measures enacted to curb disease transmission, have had broad psychosocial impact on patients and healthcare workers alike. These changes can significantly affect diagnosing and managing behavioral emergencies such as agitation in the emergency department. On behalf of the American Association for Emergency Psychiatry, we highlight unique considerations for patients with severe behavioral symptoms and staff members managing symptoms of agitation during COVID-19. Early detection and treatment of agitation, precautions to minimize staff hazards, coordination with security personnel and psychiatric services, and avoidance of coercive strategies that cause respiratory depression will help mitigate heightened risks to safety caused by this outbreak.
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http://dx.doi.org/10.5811/westjem.2020.5.47789DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390577PMC
May 2020

Psychiatric Emergencies for Clinicians: Emergency Department Management of Acute Drug-Induced Akathisia.

J Emerg Med 2020 Jun 30;58(6):922-926. Epub 2020 Apr 30.

Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) Lab, Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

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http://dx.doi.org/10.1016/j.jemermed.2020.03.028DOI Listing
June 2020

Patients accept screening for mental health and substance use disorders while ED clinicians support only if able to refer.

Am J Emerg Med 2020 12 8;38(12):2727-2729. Epub 2020 Apr 8.

University of Arkansas for Medical Sciences, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2020.04.014DOI Listing
December 2020

Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool.

Ann Emerg Med 2020 02 26;75(2):136-145. Epub 2019 Sep 26.

American College of Emergency Physicians, Irving, TX; Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, TX; Hofstra Northwell School of Medicine, Hempstead, NY.

Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.
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http://dx.doi.org/10.1016/j.annemergmed.2019.07.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7945005PMC
February 2020

Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool.

Ann Emerg Med 2020 02 26;75(2):136-145. Epub 2019 Sep 26.

American College of Emergency Physicians, Irving, TX; Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, TX; Hofstra Northwell School of Medicine, Hempstead, NY.

Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.
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http://dx.doi.org/10.1016/j.annemergmed.2019.07.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7945005PMC
February 2020

EXCITATION study: Unexplained in-custody deaths: Evaluating biomarkers of stress and agitation.

J Forensic Leg Med 2019 Aug 21;66:100-106. Epub 2019 Jun 21.

University of California, San Diego Medical Center, Department of Emergency Medicine, San Diego, CA, USA.

Background: Law enforcement personnel often confront violent and dangerous individuals suffering from Excited Delirium Syndrome (ExDS) who need emergent medical evaluation and treatment to optimize the best outcomes for this potentially lethal medical emergency. These subjects typically require physical restraint and use of force measures to control them. We sought to determine if stress-related biomarkers can differentiate ExDS subjects when compared with agitation and stress under other circumstances, including agitation and extreme physical exhaustion and restraint coupled with emotional stressors.

Methods: This was a prospective multi-center study enrolling a convenience sample of patients who presented with agitation or ExDS. Patients were enrolled from three academic emergency departments (ED), two in the United States and one in Canada. Three study groups (SG) included: SG1) patients brought to the ED with ExDS based on the use of standardized clinical criteria; SG2) ED patients with acute agitation who were not in a clinical state of ExDS but required sedation; SG3) a laboratory control group of subjects exercised to physical exhaustion, restrained, and psychologically stressed with threat of Conducted Energy Device (CED) activation. We examined a panel of stress-related biomarkers, including norepinephrine (NE), cortisol, copeptin, orexin A, and dynorphin (Dyn) from the blood of enrolled subjects.

Results: A total of 82 subjects were enrolled: 31 in the agitation group, 21 in the ExDS group, and 30 in the laboratory control group. Data were analyzed, comparing the findings between ExDS and the two other groups to determine if specific stress-related biomarkers are associated with ExDS. Biomarker comparisons between subjects identified with ExDS, agitation, and control groups demonstrated that cortisol levels were more elevated in the ExDS group compared with the other groups. Orexin was only significant in ExDs (with Agitated tendency but lot of variability in the group). NE and Dyn increased as response to stress in Agitated and ExDS.

Conclusions: Cortisol levels were more elevated in subjects in the ExDS group compared with the other comparison groups and orexin was elevated in ExDS compared to controls, a trend that did not reach statistical significance in the agitated group. The clinical or diagnostic significance of these difference have yet to be defined and warrants further study.
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http://dx.doi.org/10.1016/j.jflm.2019.06.009DOI Listing
August 2019

The utility of a statewide prescription drug-monitoring database vs the Current Opioid Misuse Measure for identifying drug-aberrant behaviors in emergency department patients already on opioids.

Am J Emerg Med 2020 03 17;38(3):503-507. Epub 2019 May 17.

Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.

Background: The most recent guidelines on prescribing opioids from the United States Centers for Disease Control recommend that clinicians not prescribe opioids as first-line therapy for chronic non-cancer pain. If an opioid prescription is considered for a patient already on opioids, prescribers are encouraged to check the statewide prescription drug monitoring database (PDMP). Some additional guidelines recommend screening tools such as the Current Opioid Misuse Measure (COMM) which may also help identify drug-aberrant behaviors.

Objective: To compare the PDMP and the Current Opioid Misuse Measure (COMM), a commonly-recommended screening tool for patients on opioids, in detecting drug-aberrant behaviors in patients already taking opioids at the time of ED presentation.

Methods: Patients on opioids were enrolled prospectively in a mixed urban-suburban ED seeing approximately 65,000 patients per year. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratios of the PDMP and COMM were compared against objective criteria of drug-aberrant behaviors as documented in the electronic medical record (EMR) and medical examiner databases.

Results: Compared to the COMM, the PDMP had similar sensitivity (36% vs 45%) and similar specificity (79% vs 55%), but better positive predictive value, better negative predictive value, and better diagnostic odds ratio. The combination of the PDMP and the COMM did not improve the detection of drug-aberrant behaviors.

Conclusions: The PDMP alone is a more useful as a screening instrument than either the COMM or the combination of the PDMP plus COMM in patients already taking opioids at time of ED presentation. However, the PDMP misses a majority of patients with documented drug-aberrant behaviors in the EMR, and should not be used in isolation to justify whether a particular opioid prescription is appropriate.
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http://dx.doi.org/10.1016/j.ajem.2019.05.035DOI Listing
March 2020

Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study.

Am J Emerg Med 2020 04 3;38(4):702-708. Epub 2019 Jun 3.

Department of Emergency Medicine, Keck School of Medicine, University of Southern California, 1200 N. State Street, GNH 1011, Los Angeles, CA 90033, United States of America; Leonard D. Schaeffer Center for Health Policy and Economics, Sol Price School of Public Policy, University of Southern California, 635 Downey Way Verna & Peter Dauterive Hall (VPD), Los Angeles, CA 90089, United States of America.

Background: Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients.

Methods: Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival.

Results: Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001).

Conclusions: Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.
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http://dx.doi.org/10.1016/j.ajem.2019.06.002DOI Listing
April 2020

Screening Tools Validated in the Outpatient Pain Management Setting Poorly Predict Opioid Misuse in the Emergency Department: A Pilot Study.

J Emerg Med 2019 Jun 28;56(6):601-610. Epub 2019 Apr 28.

Department of Emergency Medicine Behavioral Emergencies Research Lab (DEMBER), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

Background: Currently, no universally accepted methods exist to assess drug-related aberrant behaviors in emergency department (ED) patients. There are several screening tools to identify opioid misuse in patients with chronic pain, however, the validity of these screening tools to assess for misuse within the ED remains unclear.

Objectives: This study investigated the effectiveness of three commonly used screening tools, previously validated in outpatient pain management settings, to assess risk of opioid misuse in ED patients.

Methods: This was a prospective observational study of 154 participants (median age 50 years; 49.6% female) presenting to an academic ED for a chief complaint of pain ≥ 6 months or an opioid refill request. Participants completed the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain-Revised, and the Current Opioid Misuse Measure. Scores for each were compared with electronic medical record (EMR) data alone or a reference standard comprising EMR + statewide prescription drug monitoring program (PDMP) + medical examiner database.

Results: Using the combined reference standard, 55.8% of participants displayed at least one aberrant behavior. Regardless of the reference standard, the test characteristics of these screening tools were modest at best, with likelihood ratios close to 1.

Conclusion: Three screening tools previously validated in outpatient pain management settings poorly categorized risk among ED patients with chronic noncancer pain or requests for opioid refills, and should not be used to assess drug-aberrant behaviors in the ED. Review of the EMR alone or together with the PDMP may be more useful methods to assess drug-aberrant behaviors in the ED setting.
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http://dx.doi.org/10.1016/j.jemermed.2019.03.018DOI Listing
June 2019

Cryptococcal Meningoencephalitis Presenting as a Psychiatric Emergency.

J Emerg Med 2019 Aug 20;57(2):203-206. Epub 2019 Apr 20.

Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.

Background: Organic conditions can often mimic neuropsychiatric disorders, leading to delays in diagnosis and treatment for the most vulnerable populations presenting to the emergency department (ED).

Case Report: Here we discuss a case of cryptococcal meningoencephalitis seemingly consistent with psychosis on initial evaluation, and present strategies to recognize and treat this condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to the indolent time course of this disease, initial symptoms of altered mental status and personality changes may be attributed to drug use or psychiatric illness before more overt evidence for increased intracranial pressure and neurologic infection develops. It is important for emergency clinicians to maintain a high level of suspicion for this condition in at-risk patients and reassess them frequently during their ED visit.
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http://dx.doi.org/10.1016/j.jemermed.2019.03.016DOI Listing
August 2019

A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients.

West J Emerg Med 2019 Mar 19;20(2):393-402. Epub 2019 Feb 19.

Morristown Medical Center, Department of Emergency Medicine, Morristown, New Jersey.

Introduction: Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on "Special Populations: Agitation in the Elderly" from the 2016 Coalition on Psychiatric Emergencies' first Research Consensus Conference on Acute Mental Illness.

Methods: Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance.

Results: Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium.

Conclusion: It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.
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http://dx.doi.org/10.5811/westjem.2019.1.39262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404700PMC
March 2019

Emergency Medicine Research Priorities for Early Intervention for Substance Use Disorders.

West J Emerg Med 2019 Mar 19;20(2):386-392. Epub 2019 Feb 19.

University of Pittsburgh, Department of Psychiatry, Pittsburgh, Pennsylvania.

Introduction: Patients with substance use disorders (SUDs) frequently seek emergency care, and the emergency department (ED) may be their only point of contact with the healthcare system. While the ED visit has been increasingly recognized as providing opportunity for interventions around substance use, many questions remain.

Methods: In December 2016 the Coalition on Psychiatric Emergencies (CPE) convened the first Research Consensus Conference on Acute Mental Illness, which consisted of clinical researchers, clinicians from emergency medicine, emergency psychiatry, emergency psychology, representatives from governmental agencies and patient advocacy groups. Background literature review was conducted prior to the meeting, and questions were iteratively focused, revised, voted on and ranked by perceived importance using nominal group method.

Results: The main goal of the SUD workgroup was to identify research priorities and develop a research agenda to improve the early identification of and management of emergency department (ED) patients with SUDs with the goal of improving outcomes. This article is the product of a breakout session on "Special Populations: Substance Use Disorder." The workgroup identified with high consensus six research priorities for their importance related to the care of ED patients with SUDs in these overall domains: screening; ED interventions; the role of peer navigators; initiation of SUD management in the ED; specific patient populations that may impact the effectiveness of interventions including sociogenerational and cultural factors; and the management of the acutely intoxicated patient.

Conclusion: Emergency providers are increasingly recognizing the important role of the ED in reducing adverse outcomes associated with untreated SUDs. Additional research is required to close identified knowledge gaps and improve care of ED patients with SUD.
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http://dx.doi.org/10.5811/westjem.2019.1.39261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404722PMC
March 2019

Opportunities for Research in Mental Health Emergencies: Executive Summary and Methodology.

West J Emerg Med 2019 Mar 19;20(2):380-385. Epub 2019 Feb 19.

Morristown Memorial Hospital, Morristown, New Jersey.

Introduction: Despite the ever-increasing numbers of mental health patients presenting to United States emergency departments, there are large gaps in knowledge about acute care of the behavioral health patient. To address this important problem, the Coalition on Psychiatric Emergencies convened a research consensus conference in December 2016 consisting of clinical researchers, clinicians from emergency medicine, psychiatry and psychology, and representatives from governmental agencies and patient advocacy groups.

Methods: Participants used a standardized methodology to select and rank research questions in the order of importance to both researchers and patients.

Results: Three working groups (geriatrics, substance use disorders, and psychosis) reached consensus on 26 questions within their respective domains. These questions are summarized in this document.

Conclusion: The research consensus conference is the first of its kind to include non-clinicians in helping identify knowledge gaps in behavioral emergencies. It is hoped that these questions will prove useful to prioritize future research within the specialty.
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http://dx.doi.org/10.5811/westjem.2019.1.39260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404701PMC
March 2019

Author Correction: Mkk4 and Mkk7 are important for retinal development and axonal injury-induced retinal ganglion cell death.

Cell Death Dis 2019 Jan 25;10(2):64. Epub 2019 Jan 25.

Department of Ophthalmology, University of Rochester Medical Center, Rochester, NY, USA.

There was an error introduced into Figures 4, 5, and 7 during the proofing stage which has since been corrected.
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http://dx.doi.org/10.1038/s41419-018-1233-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347662PMC
January 2019

Study Enrollment When "Preconsent" Is Utilized for a Randomized Clinical Trial of Two Treatments for Acute Agitation in the Emergency Department.

Acad Emerg Med 2019 05 15;26(5):559-566. Epub 2019 Jan 15.

Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR.

Background: Acute agitation in the emergency department (ED) represents a danger to both patients and their caregivers. Medication is often needed, and few high-quality randomized trials have evaluated the optimal drugs for this vulnerable population. In the United States, as of 2017, randomized trials of drugs typically cannot be conducted under Waiver of Consent (46 CFR 45.116), and Exception From Informed Consent trials (21 CFR 50.24) are limited to life-threatening conditions, are onerous, and require filing an investigational new drug application with the FDA. We sought to conduct a randomized double-dummy trial of inhaled loxapine versus intramuscular haloperidol + lorazepam for acute agitation in the ED by obtaining consent in advance ("preconsent") in patients at risk of future agitation, allowing study drug administration up to 3 years later if the patient presented with acute agitation.

Objective: We sought to report the successful enrollment rate of patients preconsented at an earlier ED visit for this trial.

Methods: This was an analysis of patients age 18 to 64 with bipolar I disorder or schizophrenia preconsented for enrollment in the trial (clinicaltrials.gov, NCT02877108) conducted at a single urban academic center seeing approximately 60,000 patients per year. Eligible patients were assessed for capacity to consent by trained research associates, and informed consent was obtained at an ED visit for the possibility of administering drugs for agitation within the next 3 years. In the event the patient later presented to the ED and the attending physician deemed the patient required treatment for acute agitation, preconsent was confirmed and study drug would be administered.

Results: Over 67 days, 1,461 patients were screened in the ED, 269 had bipolar I or schizophrenia, 194 of whom had a contraindication to inhaled loxapine leaving 75 eligible patients; preconsent was obtained in 43 patients. Four additional patients who had not preconsented were consented for the trial in real time (three by surrogate, one patient had capacity while agitated) resulting in a total of 47 consented patients. Of these 47, a total of 12 were later removed from the study: 10 patients had unrecognized exclusion criteria for inhaled loxapine, one preconsented patient contacted the investigators at a later date and asked to be removed, and one surrogate revoked consent immediately after providing it. Only two patients were successfully enrolled, neither by preconsent: one was enrolled via a surrogate the day of enrollment, and the other was mildly agitated and had capacity to consent. The remaining patient with a valid surrogate consent did not receive study medication.

Conclusions: Utilization of preconsent to enroll patients in a randomized trial of treatments for acute agitation in the ED requires substantial resources and may not be feasible.
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http://dx.doi.org/10.1111/acem.13673DOI Listing
May 2019

Mkk4 and Mkk7 are important for retinal development and axonal injury-induced retinal ganglion cell death.

Cell Death Dis 2018 10 26;9(11):1095. Epub 2018 Oct 26.

Department of Ophthalmology, University of Rochester Medical Center, Rochester, NY, USA.

The mitogen-activated protein kinase (MAPK) pathway has been shown to be involved in both neurodevelopment and neurodegeneration. c-Jun N-terminal kinase (JNK), a MAPK important in retinal development and after optic nerve crush injury, is regulated by two upstream kinases: MKK4 and MKK7. The specific requirements of MKK4 and MKK7 in retinal development and retinal ganglion cell (RGC) death after axonal injury, however, are currently undefined. Optic nerve injury is an important insult in many neurologic conditions including traumatic, ischemic, inflammatory, and glaucomatous optic neuropathies. Mice deficient in Mkk4, Mkk7, and both Mkk4 and Mkk7 were generated. Immunohistochemistry was used to study the distribution and structure of retinal cell types and to assess RGC survival after optic nerve injury (mechanical controlled optic nerve crush (CONC)). Adult Mkk4- and Mkk7-deficient retinas had all retinal cell types, and with the exception of small areas of disrupted photoreceptor lamination in Mkk4-deficient mice, the retinas of both mutants were grossly normal. Deficiency of Mkk4 or Mkk7 reduced JNK signaling in RGCs after axonal injury and resulted in a significantly greater percentage of surviving RGCs 35 days after CONC as compared to wild-type controls (Mkk4: 51.5%, Mkk7: 29.1%, WT: 15.2%; p < 0.001). Combined deficiency of Mkk4 and Mkk7 caused failure of optic nerve formation, irregular retinal axonal trajectories, disruption of retinal lamination, clumping of RGC bodies, and dendritic fasciculation of dopaminergic amacrine cells. These results suggest that MKK4 and MKK7 may serve redundant and unique roles in molecular signaling important for retinal development and injury response following axonal insult.
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http://dx.doi.org/10.1038/s41419-018-1079-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203745PMC
October 2018

Psychiatric Emergencies for Clinicians: Emergency Department Management of Hypercalcemia.

J Emerg Med 2018 Nov 15;55(5):688-692. Epub 2018 Oct 15.

Department of Emergency Medicine, UC San Diego Health System, San Diego, California.

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http://dx.doi.org/10.1016/j.jemermed.2018.07.018DOI Listing
November 2018

Medical Screening of Mental Health Patients in the Emergency Department: A Systematic Review.

J Emerg Med 2018 Dec 10;55(6):799-812. Epub 2018 Oct 10.

University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) lab, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

Background: Patients presenting to the emergency department (ED) with psychiatric complaints often require medical screening to evaluate for a medical cause of their symptoms.

Objective: We sought to evaluate the existing literature on the medical screening of psychiatric patients and establish recommendations for ideal screening practices in Western-style EDs.

Methods: PubMed, PsycINFO, and ClinicalTrials.gov were searched for clinical studies examining the medical screening of adult psychiatric patients in the ED or inappropriate referrals to psychiatry. Articles were graded using the Effective Public Health Practice Project (EPHPP) grading tool and sorted into topics. A 3-level grading algorithm used by other emergency medicine organizations was used to evaluate the strength of the evidence for each recommendation.

Results: Sixty articles met the inclusion and exclusion criteria. Most published literature on medical screening consisted of nonrandomized studies with a high risk of bias. Some screening procedures, such as history and physical examination, were extensively recommended. Other screening procedures received mixed recommendations.

Conclusions: Based on available literature, physician experts developed 7 recommendations. For a patient with known psychiatric disease presenting with symptom exacerbation, medical screening should include a full medical and psychiatric history, a targeted physical examination, and a mental status examination. Urine toxicology screening and nonurine drug screen laboratory testing should not be routinely performed. Additional screening tests may be valuable for patients with new-onset psychiatric symptoms who are ≥65 years of age, are immunosuppressed, or have concomitant medical disease. However, additional studies on this topic with more rigorous methodology must be conducted to establish definitive guidelines.
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http://dx.doi.org/10.1016/j.jemermed.2018.09.014DOI Listing
December 2018

EVI1 overexpression reprograms hematopoiesis via upregulation of Spi1 transcription.

Nat Commun 2018 10 12;9(1):4239. Epub 2018 Oct 12.

Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, 14642, USA.

Inv(3q26) and t(3:3)(q21;q26) are specific to poor-prognosis myeloid malignancies, and result in marked overexpression of EVI1, a zinc-finger transcription factor and myeloid-specific oncoprotein. Despite extensive study, the mechanism by which EVI1 contributes to myeloid malignancy remains unclear. Here we describe a new mouse model that mimics the transcriptional effects of 3q26 rearrangement. We show that EVI1 overexpression causes global distortion of hematopoiesis, with suppression of erythropoiesis and lymphopoiesis, and marked premalignant expansion of myelopoiesis that eventually results in leukemic transformation. We show that myeloid skewing is dependent on DNA binding by EVI1, which upregulates Spi1, encoding master myeloid regulator PU.1. We show that EVI1 binds to the -14 kb upstream regulatory element (-14kbURE) at Spi1; knockdown of Spi1 dampens the myeloid skewing. Furthermore, deletion of the -14kbURE at Spi1 abrogates the effects of EVI1 on hematopoietic stem cells. These findings support a novel mechanism of leukemogenesis through EVI1 overexpression.
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http://dx.doi.org/10.1038/s41467-018-06208-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6185954PMC
October 2018

Telephoned, Texted, or Typed Out: A Randomized Trial of Physician-Patient Communication After Emergency Department Discharge.

J Emerg Med 2018 10 1;55(4):573-581. Epub 2018 Sep 1.

Department of Emergency Medicine, UC San Diego Health System, University of California at San Diego, San Diego, California.

Background: Novel means of emergency department (ED) post-discharge communication-telephone callbacks and text messages-are increasingly being utilized to facilitate patient-oriented outcomes, such as ED revisits, patient adherence, and satisfaction.

Objective: The primary measure of interest is the rate of ED revisits in the week after discharge. The secondary measures of interests are rate of primary medical doctor (PMD) or specialist physician contact in the week after discharge and patient satisfaction.

Methods: Pilot randomized controlled trial with three groups: usual discharge; usual care + phone call 48 h after discharge asking if patients wanted to speak with a physician; or usual care + text message 48 h after discharge asking if patients wanted to speak with a physician. All participants received a 1-week assessment of patient satisfaction. ED revisit and contact with PMD or specialist physician within 7 days of discharge were obtained from electronic medical record and analyzed using χ test.

Results: Two hundred and fifty-one patients were enrolled and randomized (66 control, 103 phone, 82 text). Although the three groups did not show a statistically significant difference, the phone and text groups had similar and lower proportions of patients revisiting the ED (>50% reduction) and calling or visiting their PMD or specialist physician (approximately 30% reduction) than the control group (χ = 4.57, degrees of freedom [df] = 2, p = 0.10; χ = 1.36, df = 2, p = 0.51). There was no difference in patient satisfaction (χ = 2.88, df = 2, p = 0.24).

Conclusions: Patients who are contacted for ED follow-up by phone and text, though perhaps not more satisfied, may tend to revisit the ED and contact their PMD or specialty physician less often than patients receiving standard written discharge instructions. However, this pilot study is underpowered, so larger randomized studies are needed to confirm.
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http://dx.doi.org/10.1016/j.jemermed.2018.07.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163067PMC
October 2018

Telephoned, Texted, or Typed Out: A Randomized Trial of Physician-Patient Communication After Emergency Department Discharge.

J Emerg Med 2018 10 1;55(4):573-581. Epub 2018 Sep 1.

Department of Emergency Medicine, UC San Diego Health System, University of California at San Diego, San Diego, California.

Background: Novel means of emergency department (ED) post-discharge communication-telephone callbacks and text messages-are increasingly being utilized to facilitate patient-oriented outcomes, such as ED revisits, patient adherence, and satisfaction.

Objective: The primary measure of interest is the rate of ED revisits in the week after discharge. The secondary measures of interests are rate of primary medical doctor (PMD) or specialist physician contact in the week after discharge and patient satisfaction.

Methods: Pilot randomized controlled trial with three groups: usual discharge; usual care + phone call 48 h after discharge asking if patients wanted to speak with a physician; or usual care + text message 48 h after discharge asking if patients wanted to speak with a physician. All participants received a 1-week assessment of patient satisfaction. ED revisit and contact with PMD or specialist physician within 7 days of discharge were obtained from electronic medical record and analyzed using χ test.

Results: Two hundred and fifty-one patients were enrolled and randomized (66 control, 103 phone, 82 text). Although the three groups did not show a statistically significant difference, the phone and text groups had similar and lower proportions of patients revisiting the ED (>50% reduction) and calling or visiting their PMD or specialist physician (approximately 30% reduction) than the control group (χ = 4.57, degrees of freedom [df] = 2, p = 0.10; χ = 1.36, df = 2, p = 0.51). There was no difference in patient satisfaction (χ = 2.88, df = 2, p = 0.24).

Conclusions: Patients who are contacted for ED follow-up by phone and text, though perhaps not more satisfied, may tend to revisit the ED and contact their PMD or specialty physician less often than patients receiving standard written discharge instructions. However, this pilot study is underpowered, so larger randomized studies are needed to confirm.
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http://dx.doi.org/10.1016/j.jemermed.2018.07.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163067PMC
October 2018

Safety of Risperidone for Acute Agitation and Alcohol Intoxication in Emergency Department Patients.

J Emerg Med 2017 Oct;53(4):530-535

Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Emergency Medicine, Behavioral Emergencies Research Laboratory, Little Rock, Arkansas.

Background: Acute agitation in the setting of alcohol intoxication is commonly encountered in the Emergency Department (ED). In this setting, expert consensus guidelines recommend haloperidol over second-generation antipsychotics due to their limited safety data in alcohol intoxication.

Objective: The primary objective was to compare vital sign changes prior to and after risperidone administration between ED patients presenting with alcohol intoxication [ETOH (+)] and without alcohol intoxication [ETOH (-)]. The secondary objective was to assess the effect of benzodiazepine co-administration with risperidone on vital signs.

Methods: This was a retrospective chart review of patients who received oral risperidone for acute agitation at two university EDs between January 1, 2012 and December 31, 2015. Vital signs (oxygen saturation, systolic and diastolic blood pressure, heart rate, and respiratory rate) were compared in patients who had ingested alcohol with those who had not.

Results: There were 785 patients without evidence of alcohol intoxication who received risperidone in the ED, and 52 patients with alcohol intoxication who received risperidone. Overall, risperidone with and without alcohol intoxication and benzodiazepine administration had no statistically significant effect on vital signs (p = ns for all comparisons).

Conclusion: This study suggests that oral risperidone may be a safe option for acute agitation in patients presenting to the ED with alcohol intoxication.
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http://dx.doi.org/10.1016/j.jemermed.2017.05.028DOI Listing
October 2017

Treatment Goal for Agitation: Sedation or Calming.

Ann Emerg Med 2017 11;70(5):751-752

Office of Behavioral Health, Department of Human Services, State of Colorado; Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, CO.

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http://dx.doi.org/10.1016/j.annemergmed.2017.06.017DOI Listing
November 2017

Treatment Goal for Agitation: Sedation or Calming.

Ann Emerg Med 2017 11;70(5):751-752

Office of Behavioral Health, Department of Human Services, State of Colorado; Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, CO.

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http://dx.doi.org/10.1016/j.annemergmed.2017.06.017DOI Listing
November 2017
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