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To derive and initially validate a brief bedside clinical decision support tool that identifies emergency department patients at high risk of substantial, persistent posttraumatic stress symptoms after a motor vehicle collision.Derivation (n=1,282, 19 ED sites) and validation (n=282, 11 separate ED sites) data were obtained from adults prospectively enrolled in the Advancing Understanding of RecOvery afteR traumA study who were discharged from the ED after motor vehicle collision-related trauma. The primary outcome was substantial posttraumatic stress symptoms at 3 months (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 ≥38). Logistic regression derivation models were evaluated for discriminative ability using the area under the curve and the accuracy of predicted risk probabilities (Brier score). Candidate posttraumatic stress predictors assessed in these models (n=265) spanned a range of sociodemographic, baseline health, peritraumatic, and mechanistic domains. The final model selection was based on performance and ease of administration.Significant 3-month posttraumatic stress symptoms were common in the derivation (27%) and validation (26%) cohort. The area under the curve and Brier score of the final 8-question tool were 0.82 and 0.14 in the derivation cohort and 0.76 and 0.17 in the validation cohort.This simple 8-question tool demonstrates promise to risk-stratify individuals with substantial posttraumatic stress symptoms who are discharged to home after a motor vehicle collision. Both external validation of this instrument, and work to further develop more accurate tools, are needed. Such tools might benefit public health by enabling the conduct of preventive intervention trials and assisting the growing number of EDs that provide services to trauma survivors aimed at promoting psychological recovery.

Objective To characterize risk factors for and consequences of post-traumatic stress disorder (PTSD) among older adults evaluated in the emergency department (ED) following motor vehicle collision (MVC). Design Prospective multicenter longitudinal study (2011–2015). Setting 9 EDs across the United States. Participants Adults aged 65 years and older who presented to an ED after MVC without severe injuries. Measurements PTSD symptoms were assessed 6 months after the ED visit using the Impact of Event Scale-Revised. Results Of 223 patients, clinically significant PTSD symptoms at 6 months were observed in 21% (95% CI 16%–26%). PTSD symptoms were more common in patients who did not have a college degree, had depressive symptoms prior to the MVC, perceived the MVC as life-threatening, had severe ED pain, and expected their physical or emotional recovery time to be greater than 30 days. Three factors (ED pain severity [0–10 scale], perceived life-threatening MVC [0–10 scale], and pre-MVC depressive symptoms [yes to either of two questions]), predicted 6-month PTSD symptoms with an area under the curve of 0.76. Compared to patients without PTSD symptoms, those with PTSD symptoms were at higher risk for persistent pain (72% versus 30%), functional decline (67% versus 42%), and new disability (49% versus 18%). Conclusions Among older adults treated in the ED following MVC, clinically significant PTSD symptoms at 6 months were present in 21% of patients and were associated with adverse health outcomes. Increased risk for PTSD development can be identified with moderate accuracy using information readily available in the ED.

Background Patients with traumatic intracranial hemorrhage and mild traumatic brain injury (mTIH) receive broadly variable care which often includes transfer to a trauma center, neurosurgery consultation and ICU admission. However, there may be a low risk cohort of patients who can be managed without utilizing such significant resources. Objective Describe mTIH patients who are at low risk of clinical or radiographic decompensation and can be safely managed in an ED observation unit (EDOU). Methods Retrospective evaluation of patients age≥16, GCS≥13 with ICH on CT. Primary outcomes included clinical/neurologic deterioration, CT worsening or need for neurosurgery. Results 1185 consecutive patients were studied. 814 were admitted and 371 observed patients (OP) were monitored in the EDOU or discharged from the ED after a period of observation. None of the OP deteriorated clinically. 299 OP (81%) had a single lesion on CT; 72 had mixed lesions. 120 patients had isolated subarachnoid hemorrhage (iSAH) and they did uniformly well. Of the 119 OP who had subdural hematoma (SDH), 6 had worsening CT scans and 3 underwent burr hole drainage procedures as inpatients due to persistent SDH without new deficit. Of the 39 OP who had cerebral contusions, 3 had worsening CT scans and one required NSG admission. No patient returned to the ED with a complication. Follow-up was obtained on 81% of OP. 2 patients with SDH required burr hole procedure >2weeks after discharge. Conclusions Patients with mTIH, particularly those with iSAH, have very low rates of clinical or radiographic deterioration and may be safe for monitoring in an emergency department observation unit.

Background The Patient Protection and Affordable Care Act supports the establishment of accountable care organizations (ACOs) as care delivery models designed to save costs. The potential for these cost savings has been demonstrated in the primary care and inpatient populations, but not for patients with emergency conditions or traumatic injuries. Methods Our study evaluated adult trauma patients transferred to the tertiary care hospitals of a pioneer ACO, comparing those who were transferred from within the ACO to those from outside the ACO in terms of overall cost of hospitalization. Hospital length of stay and number of imaging studies were predetermined secondary outcomes. Results The study population included 7696 hospitalizations for traumatic injuries over a 5-year period, 85.1% of which were for patients transferred from outside the ACO. Patients transferred from within the ACO had a 7.2% lower overall cost of hospitalization ( P = .032). Mean injury severity scores were not significantly different between groups. Differences in mortality, intensive care unit length of stay, and overall hospital length of stay were not significant. However, analysis of radiology studies performed during the hospitalization revealed that patients transferred from within the ACO had, on average, 0.47 fewer advanced imaging studies per hospitalization than did those transferred from outside the ACO (3.55 vs 4.02 studies per hospitalization, P = .003). Conclusions Adult trauma patients transferred from within an ACO have significantly lower total costs of hospitalization than do those transferred from outside the system, without significant differences in disease burden, hospital length of stay, or mortality.

The μ-opioid receptor 1 (OPRM1) binds endogenous opioids. Increasing evidence suggests that endogenous OPRM1 agonists released at the time of trauma may contribute to the development of posttraumatic musculoskeletal pain (MSP). In this prospective observational study, we evaluated the hypothesis that individuals with an AG or GG genotype at the OPRM1 A118 G allele, which results in a reduced response to opioids, would have less severe MSP 6 weeks after motor vehicle collision (MVC). Based on previous evidence, we hypothesized that this effect would be sex-dependent and most pronounced among women with substantial peritraumatic distress. European American men and women ≥18 years of age presenting to the emergency department after MVC and discharged to home after evaluation (N = 948) were enrolled. Assessments included genotyping and 6-week evaluation of overall MSP severity (0–10 numeric rating scale). In linear regression modeling, a significant A118 G Allele × Sex interaction was observed: an AG/GG genotype predicted reduced MSP severity among women with substantial peritraumatic distress (β = –.925, P = .014) but not among all women. In contrast, men with an AG/GG genotype experienced increased MSP severity at 6 weeks (β = .827, P = .019). Further studies are needed to understand the biologic mechanisms mediating observed sex differences in A118 G effects. Perspective These results suggest a sex-dependent mechanism by which an emotional response to trauma (distress) contributes to a biologic mechanism (endogenous opioid release) that increases MSP in the weeks after stress exposure. These results also support the hypothesis that endogenous opioids influence pain outcomes differently in men and women.

Background: Few data exist on the frequency with which multidetector computed axial tomography (MDCT) scan of the coronary arteries changes the admission decisions of emergency physicians (EP) caring for patients with possible acute coronary syndrome (ACS). We measured if and how often these changes in decision-making would occur. Methods: The theoretical dispositions of 27 emergency department patients who presented with possible ACS were determined by four board-certified EPs after case presentations. Paired disposition decisions were made before and after knowledge of the MDCT scan results. Patients were selected from a sample of 103 from a prior study. Results: The study included 27 patients with a mean age of 55 ± 9 years; 58% were male. The low-, intermediate-, and high-risk MDCT scan results were evenly distributed, as were the original providers' standard clinical risk assessments of ACS. Three patients had ACS and all were admitted both before and after review of MDCT scan results. Among 24 patients without ACS, a decision to admit was changed to discharge in 16 of 90 admission decisions (18%, 95% confidence interval [CI] 10–26%). Among 6 patients with projected discharges, 2 were inappropriately admitted after review of MDCT scan results. The odds ratio of discharge for patients without ACS increased by 3.95 (95% CI 1.96–7.95) after introduction of the MDCT scan results. Conclusion: An MDCT scan of the coronary arteries will likely change emergency physicians' decisions on the disposition of patients presenting with possible ACS, many to appropriate discharges but also a minority to inappropriate admissions.

Little is known about gender differences in the treatment of pain after motor vehicle collisions (MVCs) in an emergency department (ED). We aimed to describe gender differences in pain experiences and treatment, specifically the use of opioids and benzodiazepines after ED discharge, for MVC-related pain.This was a secondary analysis of previously collected data from the CRASH Injury studies. We included patients who were seen and discharged from an ED after an MVC and who were enrolled in 1 of 2 multicenter longitudinal prospective cohort studies (1 black/non-Hispanic and 1 white/non-Hispanic). First, we compared the experience of pain as defined by self-reported moderate-to-severe axial pain, widespread pain, number of somatic symptoms, pain catastrophizing, and peritraumatic distress between women and men using bivariate analyses. We then determined whether there were gender differences in the receipt of prescription medications for post-MVC pain symptoms (opioids and benzodiazepines) using multivariate logistic regression adjusting for demographic characteristics, pain, and collision characteristics.In total, 1878 patients were included: 61.4% were women. More women reported severe symptoms on the pain catastrophizing scale (36.8% vs 31.0%; P = 0.032) and peritraumatic distress following the MVC (59.7% vs 42.5%; P0.001), and women reported more somatic symptoms than men (median, 3.9; interquartile range, 3.7-4.0 vs median, 3.3; interquartile range, 3.1-3.5; P0.001). Unadjusted, similar proportions of women and men were given opioids (29.2% vs 29.7%; P = 0.84). After adjusting for covariates, women and men remained equally likely to receive a prescription for opioids (relative risk = 0.83; 95% confidence interval, 0.58-1.19). Women were less likely than men to receive a benzodiazepine at discharge from an ED (relative risk = 0.53; 95% confidence interval, 0.32-0.88).In a large, multicenter study of ED patients treated for MVC, there were gender differences in the acute psychological response to MVC with women reporting more psychological and somatic symptoms. Women and men were equally likely to receive opioid prescriptions at discharge. Future research should investigate potential gender-specific interventions to reduce both posttraumatic distress and the risk of developing negative long-term outcomes like chronic pain.

a t i r. David Peak: Today’s case is that of a 23-year-old ale who was brought to the Emergency Department ED) by Emergency Medical Services (EMS) after being tabbed repeatedly by an assailant who broke into his partment. Paramedics found him seated with multiple tab wounds to his anterior chest and abdomen. The atient was awake, alert and agitated. Vital signs were: eart rate (HR) 120 beats per minute, systolic blood ressure (BP) 110 mm Hg, and respiratory rate (RR) 18 reaths per minute. Breath sounds were reportedly symetrical. He was placed on oxygen by non-rebreather ace mask, two large-bore antecubital intravenous (i.v.) ines were inserted, and boluses of normal saline were dministered. During the brief transport to the hospital, is mental status deteriorated from agitation to lethargy. Dr. Eric Nadel: Are there any questions about the nitial presentation? Dr. Tracy Wimbush: Was there any other informaion about the patient or the weapon used? Dr. Peak: The patient was an otherwise healthy male ith no past medical or surgical history, allergies or edications. There was no evidence of drug parapheralia at the scene. Details on the knife were unavailable. The patient arrived in the ED at 6:55 a.m., approxiately 20 minutes after being stabbed. Vital signs were P 90/50 mm Hg, HR 130 beats/minute, RR 30 breaths/ inute, and oxygen saturation 92% on the non-rereather oxygen mask. The primary survey revealed that e was somnolent, verbalizing only with physical stim

We have isolated two cathepsin B (CTSB)-encoding cDNAs, h CBF 1 and h CBF2 , from a normal human embryonic fibro blast library. These clones demonstrate 98% identity to overlapping regions of published human hepatoma and kidney CTSB cDNAs, but show some interesting differences from the published sequences in the 3′-untranslated region (3′- UTR ). Both h CBF1 and h CBF2 contain a 10-bp insertion in the 3′- UTR that may permit formation of a highly stable stem-loop structure not present in mRNAs without this insertion. Our h CBF1 cDNA also contains a 1019-bp extension of the 3′- UTR sequence that resembles the long 3′- utr reported for murine CTSB cDNAs. Probes unique to this 3′- UTR extension hybridize to 4.0- and 1.7-kb CTSB RNAs on Northern blots, but not to the major 2.2-kb mRNA transcript. Our data reveal variations in normal human CTSB transcripts that result from differences in the length of the 3′- UTR , as well as the presence or absence of a stem-loop stabilizing sequence.

s The Journal of Pain S35 (236) African Americans are at increased risk of developing chronic pain and itch at the site of tissue autograft following major thermal burn injury A Liu, A Bermudez, J Hu, S Jones, J Hwang, J Smith, L Ballina, A Patel, T Tran, R Karlnoski, D Smith, B Cairns, and S McLean; University of North Carolina

s The Journal of Pain S35 (236) African Americans are at increased risk of developing chronic pain and itch at the site of tissue autograft following major thermal burn injury A Liu, A Bermudez, J Hu, S Jones, J Hwang, J Smith, L Ballina, A Patel, T Tran, R Karlnoski, D Smith, B Cairns, and S McLean; University of North Carolina