Drinking patterns and problems and drinking in the event: an analysis of injury by cause among casualty patients

Alcohol and the Risk of Injury

Globally, almost four and a half million people died from injury in 2019. Alcohol's contribution to injury-related premature loss of life, disability and ill-health is pervasive, touching individuals, families and societies throughout the world. We conducted a review of research evidence for alcohol's causal role in injury by focusing on previously published systematic reviews, meta-analyses and where indicated, key studies. The review summarises evidence for pharmacological and physiological effects that support postulated causal pathways, highlights findings and knowledge gaps relevant to specific forms of injury (i.e., violence, suicide and self-harm, road injury, falls, burns, workplace injuries) and lays out options for evidence-based prevention.

Breathalysing and surveying river users in Australia to understand alcohol consumption and attitudes toward drowning risk

BACKGROUND

Little is known about people's river usage, a leading drowning location. This study examines alcohol consumption patterns of river users and their attitudes to drowning risk.

METHODS

A convenience sample of adult (18+ years) river users were surveyed at four river locations. The survey covered eight domains: demographics; river attendance frequency; frequency of engaging in water activities; drinking patterns; alcohol and water safety knowledge; alcohol and water safety attitudes; alcohol consumption; and Blood Alcohol Concentration (BAC). For BAC, participants were asked to record time since their last alcoholic drink and were then breathalysed to record an estimate of their BAC. BAC was examined by BAC reading (negative, positive, ≥0.050%). Hazardous lifetime drinking levels were calculated and their impact on drowning risk evaluated. Univariate and chi square analysis (95% confidence interval) was conducted.

RESULTS

Six hundred eighty four people participated (51.6% female; 49.0% aged 18-34 years). Sixteen percent (15.9%) had a positive BAC (Mean + BAC = 0.068%; SD ± 0.08; Range = 0.001-0.334%), with 7.2% ≥0.050% (Mean BAC ≥0.050% =0.132%; SD ± 0.06). Those significantly more likely to record a BAC ≥0.050% at the river were: aged 18-34 years, resided in inner regional and low socio-economic areas, visited the river in the afternoon, with friends, on days with higher maximum air temperatures, frequent river users (11+ times in the last 30 days) and those who spend longer in the water (301+ minutes). River users who recorded a BAC ≥0.050% were more likely to self-report engaging in risky activities (i.e. diving into water of unknown depth and jumping into the river from height). River users on Australia day (a national public holiday) were significantly more likely to drink heavily (Mean BAC ≥0.05% = 0.175%; SD ± 0.09).

CONCLUSIONS

Despite males accounting for 85% of alcohol-related river drowning deaths, similar numbers of males and females were consuming alcohol at the river. This study has addressed a gap in knowledge by identifying river usage and alcohol consumption patterns among those at increased drowning risk. Implications for prevention include delivering alcohol-related river drowning prevention strategies to both males and females; at peak times including during hot weather, afternoons, public holidays and to river users who swim.

A multi-level analysis of emergency department data on drinking patterns, alcohol policy and cause of injury in 28 countries

BACKGROUND

While individual-level drinking pattern is an important risk factor for alcohol-related injury, societal-level pattern and alcohol policy are also important, and no research exists on the relationship of these variables with specific causes of injury.

METHODS

A probability sample of 14,142 emergency department (ED) patients from 32 ED studies in 28 countries included in the International Collaborative Alcohol and Injury Study (ICAIS) is analyzed using multilevel modeling of individual-level volume and pattern of drinking, country-level detrimental drinking pattern (DDP), and alcohol policy using the International Alcohol Policy and Injury Index (IAPII) on self-reported drinking prior to the injury event, categorized as traffic, violence, fall or other cause. The IAPII includes four domains: availability, vehicular, advertising, and drinking context.

RESULTS

Frequent heavy drinking was a strong predictor (p < .0.001) of injuries related to violence (OR = 2.57), falls (OR = 2.86), and other causes (OR = 1.71), while episodic heavy drinking was a significant predictor of injuries related to violence and falls. DDP was a significant predictor (p < 0.05) of traffic (OR = 1.54) and violence-related injuries (OR = 1.38) but lost significance when the IAPII was included. The IAPII was a significant predictor only for traffic injury (OR = 0.97, p < 0.001), and each domain with the exception of context were also significant.

CONCLUSIONS

Findings here clearly point to the importance of targeted policies for specific causes of injury as well as the importance of individual and societal drinking patterns, the latter of which may be difficult to influence by preventive measures aimed to reduce alcohol-related injury.

A comparison of alcohol positive and alcohol negative trauma patients requiring an emergency laparotomy

BACKGROUND

The effect of alcohol exposure on patients undergoing a laparotomy for trauma is unknown. The purpose of this study was to compare outcomes of morbidity and mortality between alcohol positive and alcohol negative trauma patients who required emergent laparotomies using the National Trauma Data Bank (NTDB).

METHODS

A retrospective database analysis was performed using 28,354 NTDB incident trauma cases, from 2007 through 2012, who had been tested for alcohol and who required abdominal operations (using ICD-9-CM procedure codes) within 24h of presentation. Variables used: age, gender, admission year, alcohol presence, ISS, GCS, injury type & mechanism, discharge status, hospital LOS, ICU stay, ventilator use, and hospital complications.

RESULTS

In adjusted analyses, there were no statistically significant differences between the alcohol positive and alcohol negative cohorts when evaluating in-hospital mortality (OR, 0.93; 95% CI: 0.84-1.03), likelihood of earlier hospital discharge (HR, 1.02; 95% CI: 0.99-1.05), and the all-inclusive category of in-hospital complications (OR, 1.04; 95% CI: 0.97-1.12).

CONCLUSIONS

After adjusting for age, gender, admission year, ISS, GCS, and injury mechanism, there were no major differences between the alcohol positive and alcohol negative cohorts when it came to in-hospital mortality, likelihood of earlier hospital discharge, and most of the in-hospital complications measured among adult trauma patients requiring emergency laparotomies.

Lifetime alcohol consumption and severity in alcohol dependence syndrome

INTRODUCTION

Alcohol dependence syndrome is a major public health issue globally and is responsible for significant morbidity and mortality. The total dose of alcohol consumed has been linked to liver diseases, pancreatitis, and other alcohol-related medical consequences. However, this has not been studied in relation to severity of dependence; although it is well known that alcohol causes neuronal damage, which in turn potentiates dependence. Thus, there is a need to study the relationship between the amount of alcohol consumed and severity of dependence.

MATERIALS AND METHODS

A total of 165 consecutive cases of alcohol dependence syndrome were studied in a General Hospital Psychiatry Unit at a tertiary care hospital. Addiction Severity Index (ASI) was used to evaluate the severity of alcohol dependence, and Life Time Alcohol Consumption (LTAC) was evaluated by taking careful history. Correlation coefficients were calculated between ASI and LTAC. Group differences were analyzed using t-test.

RESULTS

There was a significant correlation between ASI and LTAC (r = 0.162, P = 0.032), which was highly significant in the subgroup without medical complications (r = 0.250, P = 0.003). A similar correlation in the medical complications subgroup was not significant.

CONCLUSIONS

Lifetime alcohol consumption co-related with the severity of alcohol dependence, particularly in those presenting without medical complications (i.e., those with behavioral and social consequences, and injuries).

Patterns of Drinking and Mortality from Different Diseases—An Overview

Alcohol has been linked to a considerable burden of disease worldwide. Recent epidemiological research has shown that dimensions of alcohol exposure other than average volume are causal in the etiology of disease. Based on a systematic, computer-assisted search, this article attempts a qualitative review of this literature. Results show that cardiovascular disease, especially ischaemic heart disease, is linked to patterns of drinking: regular and light to moderate drinking, and drinking with meals are cardioprotective; heavy drinking occasions have been associated with detrimental outcomes and increases in disease risk. For cancers, consumption of spirits is linked to higher risk of cancers of the upper digestive tract. Spirits also may play a particular role in causing liver cirrhosis in addition to heavy drinking occasions. Finally, injuries are especially related to high blood alcohol concentration and to the frequency of heavy drinking occasions. Overall, these findings strongly indicate that alcohol epidemiology should include adequate pattern measures into future research.

Relative risk of injury from acute alcohol consumption: modeling the dose-response relationship in emergency department data from 18 countries

AIMS

To update and extend analysis of the dose-response relationship of injury and drinking by demographic and injury subgroups and country-level drinking pattern, and examine the validity and efficiency of the fractional polynomial approach to modeling this relationship.

DESIGN

Pair-matched case-cross-over analysis of drinking prior to injury, using categorical step-function and fractional polynomial analysis.

SETTING

Thirty-seven emergency departments (EDs) across 18 countries.

PARTICIPANTS

A total of 13 119 injured drinkers arriving at the ED within 6 hours of the event.

MEASUREMENTS

The dose-response relationship was analyzed by gender, age, cause of injury (traffic, violence, fall, other) and country detrimental drinking pattern (DDP).

FINDINGS

Estimated risks were similar between the two analytical methods, with injury risk doubling at one drink [odds ratio (OR) = 2.3-2.7] and peaking at about 30 drinks. Although risk was similar for males and females up to three drinks (OR = 4.6), it appeared to increase more rapidly for females and was significantly higher starting from 20 drinks [female OR = 28.6; confidence interval (CI) = 16.8, 48.9; male OR = 12.8; CI = 10.1, 16.3]. No significant differences were found across age groups. Risk was significantly higher for violence-related injury than for other causes across the volume range. Risk was also higher at all volumes for DDP-3 compared with DDP-2 countries.

CONCLUSIONS

There is an increasing risk relationship between alcohol and injury but risk is not uniform across gender, cause of injury or country drinking pattern. The fractional polynomial approach is a valid and efficient approach for modeling the alcohol injury risk relationship.

Blood alcohol concentration and self-reported alcohol ingestion in acute poisoned patients who visited an emergency department

Background

Many acute poisoned patients have co-ingested alcohol in the emergency department (ED). This study aimed to estimate the blood alcohol concentration (BAC) of acute poisoned patients who visited an ED by age and gender distribution and to determine whether it is possible to obtain self-reports of alcohol ingestion among poisoned patients.

Method

A retrospective medical chart review was conducted for all patients who visited the ED with acute poisoning between January 2004 and February 2008. Data regarding the patient’s age, gender, BAC, self-reported alcohol ingestion, poison ingested, time elapsed since poison exposure, presence of suicide attempts, and self-reported alcohol ingestion were collected. Patients were classified into two groups based on serum alcohol levels (≤10 mg/dl, >10 mg/dl).

Results

Of the 255 subjects, 88 subjects (34.5%) were included in the non-alcohol group and 167 subjects (65.5%) were included in the alcohol group. 227 subjects (89.0%) showed suicide intention. Using the 201 subjects who completed the self-report of alcohol ingestion, self-report resulted in 96.6% sensitivity and 86.7% specificity for the assessment of alcohol ingestion. The positive and negative predictive values for self-report were 91.2% and 94.7%, respectively. The median (interquartile range) BAC of the 97 males in the sample was 85.0 (10.0-173.5) mg/dl, and that of the 158 females was 32.0 (4.0-137.5) mg/dl (p = 0.010). The distribution of age in the groups was significantly different between the alcohol and non-alcohol groups (p = 0.035), and there was a significant difference in the mean BAC with respect to age for males (p = 0.003).

Conclusion

This study showed that over two-thirds of patients presenting with acute poisoning had a BAC > 10 mg/dl. Most of patients visited by suicide attempt. Males had a higher BAC than did females. Self-reported alcohol ingestion in acute poisoned patients showed high sensitivity and specificity.

Patterns of substance abuse treatment seeking following cocaine-related emergency department visits

Chest pain is the most common medical complaint among cocaine-using emergency department (ED) patients. Correlates of substance abuse treatment seeking were examined using 3-month post-discharge surveys from 170 ED patients admitted with cocaine-related chest pain. Four treatment categories were specified as the dependent variable in an ordered logistic regression: no treatment (74.7%), informal treatment only (7.1%), formal treatment only (5.9%), and both formal and informal treatment (12.4%). The following variables were found to be positively associated with a higher treatment category: frequency of cocaine use (OR = 1.07, CI(95) = 1.01-1.15, p = 0.03), global severity index (OR = 2.26, CI(95) = 1.04-4.90, p = 0.04), number of endorsed stigma barriers (OR = 4.40, CI(95) = 1.41-13.78, p = 0.01), interpersonal consequences (OR = 1.41, CI(95) = 1.01-1.88, p = 0.02), and pre-baseline informal treatment (OR = 6.69, CI(95) = 1.58-28.36, p = 0.01). Physical consequences were found to be negatively associated with a higher treatment category (OR = 0.63, CI(95) = 0.47-0.85, p < 0.01). ED visits for cocaine-related chest pain represent missed opportunities to link patients to substance abuse treatment, and interventions are needed to motivate patients to seek care.

Characteristics of alcohol-related injuries in adolescents visiting the emergency department

Alcohol is frequently a factor affecting emergency department patients, and alcohol consumption is more common among those who are injured. In Korea, the socioeconomic impact of alcohol has been enormous because of traditional permissive attitudes toward alcohol. Juvenile drinking has increased recently; consequently, an increase in alcohol-related injuries is likely in this population. Therefore, we compared the characteristics and severity of alcohol-related injuries in adolescents and adults. All injured patients seen at six EDs throughout 2007 were included. We obtained data from the 'Development of a model for an in-depth injury surveillance system based on the emergency department' surveillance. The proportion of adolescents who drank was 5.0%. No significant alcohol-related difference in injuries was found between male and female adolescents (P = 0.14), whereas in adults, being male was strongly related to alcohol consumption (P < 0.001). Among traffic accidents, motorcycle-related injuries were strongly associated with alcohol use in adolescents (odds ratio [OR] 2.52, 95% confidence interval [CI] 1.09-5.83). Results also indicated that alcohol-related injuries in adolescents showed poor outcomes (OR 2.36, 95% CI 1.47-3.81) as compared with those in adults (OR 1.42, 95% CI 1.26-1.59). Preventive strategy on alcohol-related injuries in adolescents should focus on reducing motorcycle accidents.

Substance use, violence, and unintentional injury in young holidaymakers visiting Mediterranean destinations

BACKGROUND

Young people's alcohol and drug use increases during holidays. Despite strong associations between substance use and both violence and unintentional injury, little is known about this relationship in young people holidaying abroad. We examine how risks of violence and unintentional injury abroad relate to substance use and the effects of nationality and holiday destination on these relationships.

METHODS

A cross-sectional comparative survey of 6,502 British and German holidaymakers aged 16 to 35 years was undertaken in airports in Cyprus, Greece, Italy, Portugal, and Spain.

RESULTS

Overall, 3.8% of participants reported having been in a physical fight (violence) on holiday and 5.9% reported unintentional injury. Two thirds reported having been drunk on holiday and over 10% using illicit drugs. Levels of drunkenness, drug use, violence, and unintentional injury all varied with nationality and holiday destination. Violence was independently associated with being male, choosing the destination for its nightlife, staying 8 to 14 days, smoking and using drugs on holiday, frequent drunkenness, and visiting Majorca (both nationalities) or Crete (British only). Predictors of unintentional injury were being male, younger, using drugs other than just cannabis on holiday, frequent drunkenness, and visiting Crete (both nationalities).

CONCLUSIONS

Violence and unintentional injury are substantial risks for patrons of international resorts offering a hedonistic nightlife. Understanding those characteristics of resorts and their visitors most closely associated with such risks should help inform prevention initiatives that protect both the health of tourists and the economy of resorts marketed as safe and enjoyable places to visit.

Feasibility and reliability of the SHOT: A short scale for measuring pretreatment severity of alcohol withdrawal in the emergency department

BACKGROUND

Use of a symptom-triggered scale to measure the severity of alcohol withdrawal could reduce the rate of seizures and other complications. The current standard scale, the Clinical Institute of Withdrawal Assessment (CIWA), takes a mean (±SD) of 5 minutes to complete, requiring 30 minutes of nursing time per patient when multiple measures are required.

OBJECTIVES

The objective was to assess the feasibility and reliability of a brief scale of alcohol withdrawal severity.

METHODS

The SHOT is a brief scale designed to assess alcohol withdrawal in the emergency department (ED). It includes four items: sweating, hallucinations, orientation, and tremor (SHOT). It was developed based on a literature review and a consensus process by emergency and addiction physicians. The SHOT was first piloted in one ED, and then a prospective observational study was conducted at a different ED to measure its feasibility and reliability. Subjects included patients who were in alcohol withdrawal. One nurse administered the SHOT and CIWA, and the physician repeated the SHOT independently. The SHOT was done only at baseline, before treatment was administered.

RESULTS

In the pilot study (12 patients), the SHOT took 1 minute to complete on average, and the CIWA took 5 minutes. Sixty-one patients participated in the prospective study. For the SHOT and the CIWA done by the same nurse, the kappa was 0.88 (95% confidence interval [CI] = 0.52 to 1.0; p < 0.0001), and the Pearson's r was 0.71 (p < 0.001). The kappa for the nurse's CIWA score and the physician's SHOT score was 0.61 (95% CI = 0.25 to 0.97; p < 0.0006), and the Pearson's r was 0.48 (p = 0.002). The SHOTs performed by the nurse and physician agreed on the need for benzodiazepine treatment in 30 of 37 cases (82% agreement, kappa = 0.35, 95% CI = 0.03 to 0.67; p < 0.02). The mean (±SD) time taken by nurses and physicians to complete the SHOT was 1 (± 0.52) minute (median = 0.6 minutes). Seventeen percent of patients scored positive on the SHOT for hallucinations or disorientation.

CONCLUSIONS

The SHOT has potential as a feasible and acceptable tool for measuring pretreatment alcohol withdrawal severity in the ED. Further research is needed to validate the SHOT, to assess the utility of serial measurements of the SHOT, and to demonstrate that its use reduces length of stay and improves clinical outcomes.

The relationship between alcohol consumption and injury in ED trauma patients

BACKGROUND

Alcohol-related injuries are significantly more serious than non-alcohol-related injuries. However, there have been few data on the relationship between alcohol consumption and injury in the Korea. This study was designed to determine the absence or presence of alcohol consumption at the time of injury and the relationship between the quantity of alcohol and the extent of injury.

MATERIALS AND METHODS

The study subjects consisted of trauma patients aged 15 years or older with the emergency department admission at 5 emergency medical centers. With the informed consent, patients were screened using the questionnaire and blood alcohol concentration. The subjects were divided into 2 groups according to the blood alcohol concentration level: the nonintoxicated and intoxicated groups. The demographic characteristics, cause of injury, injury severity, and length of hospitalization were compared between the 2 groups.

RESULTS

Of a total of 407 cases, there were 123 cases in the intoxicated group and 284 cases in the nonintoxicated group. As to the severity of injury, an Abbreviated Injury Scale was significantly higher in the head and face. Injury Severity Score was higher in intoxicated group with marginal statistical significance. There was no significant difference in the total length of hospitalization, but the length of intensive care unit admission was significantly longer in the intoxicated group than in the nonintoxicated group.

CONCLUSION

There may be no significant correlation between alcohol consumption and injury severity. However, injury severity may increase with increasing quantity of alcohol and be greater in head injuries.

The joint association of average volume of alcohol and binge drinking with hazardous driving behaviour and traffic crashes

BACKGROUND

Previous studies on alcohol-related road safety have not assessed the joint impact of average volume of alcohol and binge drinking.

AIM

To examine the joint and separate association of average volume of alcohol and binge drinking with hazardous driving behaviour and traffic crashes.

METHODS

Data were drawn from telephone interviews conducted in the period 2000-2005, with 12 037 individuals representative of the population aged 18-64 years in the Madrid region, Spain. The threshold between average moderate and heavy volumes was 40 g of alcohol/day in men and 24 g/day in women. Binge drinking was defined as intake of >or= 80 g of alcohol in men and >or= 60 g in women, during any drinking occasion in the preceding 30 days. Individuals were classified into the following categories: (i) non-drinkers; (ii) moderate drinkers with no binge drinking (MDNB); (iii) moderate drinkers with binge drinking (MDB); (iv) heavy drinkers with no binge drinking (HDNB); and (v) heavy drinkers with binge drinking (HDB). Analyses were performed using logistic regression, with adjustment for sex, age and educational level.

FINDINGS

Frequency of inadequate seat-belt use increased progressively across categories of alcohol consumption, with odds ratio (OR) 1 in non-drinkers, 1.19 [95% confidence interval (CI) 1.06-1.33] in MDNB, 1.69 (1.41-2.03) in MDB, 1.68 (1.24-2.29) in HDNB and 2.41 (1.83-3.18) in HDB (P for trend <0.001). Compared with MDNB, alcohol-impaired driving was also more frequent in MDB (OR 7.43; 95% CI: 5.52-10.00), HDNB (OR 7.31; 95% CI: 4.37-12.25) and in HDB (OR 15.50; 95% CI: 10.62-22.61). Lastly, compared with non-drinkers, frequency of traffic crashes increased progressively across categories of alcohol consumption (P for trend=0.028), although it only reached statistical significance in HDB (OR 2.01; 95% CI: 1.00-4.09).

CONCLUSIONS

Self-reported average volume of alcohol and binge drinking are both associated with self-reported hazardous driving behaviour and traffic crashes. The strength of the association is greater when average heavy consumption and binge drinking occur jointly.

Causes and circumstances of fatal falls downstairs

Reports of 9156 autopsies performed at the Centre of Legal Medicine of the J.W. Goethe-University Frankfurt over a period of 10 years were reviewed for fatal accidents of falls downstairs, age, gender, drinking behaviour and alcohol influence, the locality and the time of the accident. Among 43 cases (0.47% of all autopsies) were 31 males (72.1%, average age 63.9 years) and 12 women (27.9%, average age 65.8 years). Twenty-nine accidents (67.4%) occurred at home, in six cases (14.0%) in a public building or area. Twenty-three victims (53.5%) were under the influence of alcohol (average blood alcohol concentrations (BAC): 2.56 per thousand), in 19 persons autopsy revealed severe internal disease which may explain the cause of the fall (severe coronary artery disease, myocardial hypertrophy, myocardial infarction, apoplexy, brain tumour). This study indicates that a fatal fall downstairs without an underlying severe disease or alcohol influence is a rare phenomenon.

Frequency of heavy episodic drinking among nonfatal injury patients attending an emergency room

This study investigated the relationship between frequency of heavy episodic drinking and nonfatal injury in four categories: environment, external cause, diagnosis, and activity at the time of injury. Data were collected over 18 months at the emergency room facility of a Swedish hospital. Injury patients aged 18-70 years answered an alcohol screening questionnaire. Heavy episodic drinking was measured as drinking six glasses (72 g alcohol) or more per occasion, for both males and females. A total of 2211 patients were enrolled in the study (79.5% completion rate). Demographic and drinking characteristics for the patients were compared to those of the general population, data for which were derived from a population-based survey. The proportion of people who reported heavy episodic drinking once a month or more was nearly twice as large among the injury patients as in the general population. However, age and sex outweighed heavy episodic drinking as risk factors for most injury types. There were 11 significant associations between frequency of heavy episodic drinking and injury types in the four injury categories, yet no linear trends of increased likelihood of injury with increased frequency of heavy episodic drinking could be discerned.

Usual drinking patterns and non-fatal injury among patients seeking emergency care

OBJECTIVES

To explore the association between drinking patterns, irrespective of whether alcohol was consumed in the event of the injury or not, and different injury variables; and to identify settings and situations in which risky drinkers have an increased likelihood of injury.

STUDY DESIGN

The study population consisted of all patients aged 18-70 years registered for an injury according to ICD-10 at a Swedish emergency department during an 18-month period. After informed consent, the injury patients were screened for drinking habits by the AUDIT-C questionnaire. The gender, age and drinking pattern of injury patients were compared with the general population.

METHODS

A total of 2782 patients aged 18-70 years were registered for an injury during the study period. The number of drop-outs was 631. Drop-outs include those who did not consent to participate, were severely injured, too intoxicated or did not fill out the questionnaire satisfactory. Thus, 77.3% of the target group were included for further analysis (1944 drinkers and 207 abstainers). The patients were categorized into three drinking categories: abstainers, non-risky and risky drinkers. Risky drinkers were defined according to usual weekly consumption of 80g or more of alcohol for women and 110g or more for men and/or heavy episodic drinking (i.e. having six glasses or more one glass=12g alcohol), or both, on one occasion at least once a month, valid for both women and men. To estimate the relationship between drinking patterns and the injury variables (environment, cause of injury, activity and diagnosis), odds ratios (OR) were calculated by logistic regression. Multiple logistic regression was used in order to control for age and sex differences between the various drinking and injury categories.

RESULTS

The proportion of risky drinkers was higher in the study population compared with the general population in the same area. When controlling for age and sex, risky drinkers (OR 6.4(adj) Confidence interval CI 1.9-21.2) and non-risky drinkers (OR .4.5(adj) CI 1.4-14.5) displayed an increased risk for injury compared with abstainers, in amusement locations, parks, by or on lakes or seas, especially while engaged in play, hobby or other leisure activities (risky drinkers: OR 2.8(adj) CI 1.3-5.6; non-risky drinkers: OR 2.4(adj) CI 1.2-4.6). All differences between drinking patterns in external cause of injury disappeared when age and sex were considered. During rest, meals and attending to personal hygiene, the non-risky drinkers had a lower probability of injury compared with abstainers (OR 0.3(adj) CI 0.1-0.8). Non-risky drinkers had a higher probability than abstainers of suffering luxation (dislocation) or distortion (OR 1.6(adj) CI 1.1-2.5). Nine per cent of the study population reported that they believed that their injury was related to intake of alcohol. Half of this group were non-risky drinkers (CI for the 13.7% difference was 9.7-17.6).

CONCLUSIONS

Few significant associations between drinking pattern and injury remained when age and sex were controlled for.

Multi-level analysis of causal attribution of injury to alcohol and modifying effects: Data from two international emergency room projects

Although alcohol consumption and injury has received a great deal of attention in the literature, less is known about patient's causal attribution of the injury event to their drinking or factors which modify attribution. Hierarchical linear modeling is used to analyze the relationships of the volume of alcohol consumed prior to injury and feeling drunk at the time of the event with causal attribution, as well as the association of aggregate individual-level and socio-cultural variables on these relationships. Data analyzed are from 1955 ER patients who reported drinking prior to injury included in 35 ERs from 24 studies covering 15 countries from the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the WHO Collaborative Study on Alcohol and Injuries. Half of those patients drinking prior to injury attributed a causal association of their injury with alcohol consumption, but the rate of causal attribution varied significantly across studies. When controlling for gender and age, the volume of alcohol consumed and feeling drunk (controlling for volume) were both significantly predictive of attribution and this did not vary across studies. Those who drink at least weekly were less likely to attribute causality at a low volume level, but more likely at high volume levels than less frequent drinkers. Attribution of causality was also less likely at low volume levels in those societies with low detrimental drinking patterns, but more likely at high volume levels or when feeling drunk compared to societies with high detrimental drinking patterns. These findings have important implications for brief intervention in the ER if motivation to change drinking behavior is greater among those attributing a causal association of their drinking with injury.

Developmental differences in the sensitivity of spontaneous and miniature IPSCs to ethanol

BACKGROUND

Ethanol (EtOH) consumption by juveniles and adolescents is an important public health problem. Recent studies have indicated that adolescent animals are less sedated by EtOH than adult animals and experience less motor impairment. Thus, human adolescents may be able to consume more EtOH prior to sedation, putting them at greater risk for EtOH addiction and other negative consequences of EtOH use. However, the mechanisms underlying this developmental difference are unknown. One contributing factor may be gamma-aminobutyric acid-A (GABA(A)) receptor-mediated inhibition, which is known to produce sedation. We have shown that evoked, GABA(A) receptor-mediated inhibitory postsynaptic currents (IPSCs) are less powerfully enhanced by EtOH in neurons from juvenile or adolescent animals than in those from adult animals; however, the mechanisms of this developmental difference in sensitivity are unknown.

METHODS

Using whole-cell recording, we tested the response of spontaneous and miniature GABA(A) receptor-mediated IPSCs (sIPSCs and mIPSCs) to EtOH in rat hippocampal slices from animals representing two distinct developmental stages: adolescent and adult.

RESULTS

We found significantly greater EtOH-induced enhancement of the frequency of sIPSCs in cells from adult animals compared to those from adolescent animals. Although EtOH also increased the frequency of mIPSCs, this effect was not age dependent. EtOH did not significantly affect the kinetics of mIPSCs.

CONCLUSIONS

We conclude that the sensitivity of GABA(A) receptor-mediated inhibitory processes to EtOH increases with development from the adolescent period to adulthood, and that this is likely mediated by developmental changes in the effect of EtOH on interneuron excitation.

Alcohol-Related Social Consequences in Castille and Leon, Spain

BACKGROUND

The purpose of this study was to examine the prevalence of alcohol-related social problems, as well as to assess the relationship between alcohol-related social problems and patterns of alcohol consumption in the general population during the year 2004.

METHODS

A total of 2,500 individuals, age range from 14 to 70 years, in Castille and Leon, Spain, were surveyed in 2004 for their patterns of alcohol consumption and alcohol-related social consequences during the previous year.

RESULTS

Participants who admitted to having had some kind of social problem related to the consumption of alcohol in the previous year were 6.5%, with a mean of 2.4 alcohol-related social problems. The most frequent problems cited were "argument, discussion, or serious conflict without physical aggression" (3%).

CONCLUSIONS

The present study shows that the reporting of alcohol-related social problems was quite frequent and that having alcohol-related social problems was related to drunkenness episodes in the previous year, having 5 or more drinks on a single occasion in the previous year, and alcohol intake.

Alcohol-Attributable Injuries in Admissions to a Swiss Emergency Room-An Analysis of the Link Between Volume of Drinking, Drinking Patterns, and Preattendance Drinking

BACKGROUND

An association between alcohol consumption and injury is clearly established from volume of drinking, heavy episodic drinking (HED), and consumption before injury. Little is known, however, about how their interaction raises risk of injury and what combination of factors carries the highest risk. This study explores which of 11 specified groups of drinkers (a) are at high risk and (b) contribute most to alcohol-attributable injuries.

METHODS

In all, 8,736 patients, of whom 5,077 were injured, admitted to the surgical ward of the emergency department of Lausanne University Hospital between January 1, 2003, and June 30, 2004, were screened for alcohol use. Eleven groups were constructed on the basis of usual patterns of intake and preattendance drinking. Odds ratios (ORs) comparing injured and noninjured were derived, and alcohol-attributable fractions of injuries were calculated from ORs and prevalence of exposure groups.

RESULTS

Risk of injury increased with volume of drinking, HED, and preattendance drinking. For both sexes, the highest risk was associated with low intake, HED, and 4 (women), 5 (men), or more drinks before injury. At the same level of preattendance drinking, high-volume drinkers were at lower risk than low-volume drinkers. In women, the group of low-risk non-HED drinkers taking fewer than 4 drinks suffered 47.5% of the alcohol-attributable injuries in contrast to only 20.4% for men. Low-volume male drinkers with HED had more alcohol-attributable injuries than that of low-volume female drinkers with HED (46.9% vs 23.2%).

CONCLUSIONS

Although all groups of drinkers are at increased risk of alcohol-related injury, those who usually drink little but on occasion heavily are at particular risk. The lower risk of chronic heavy drinkers may be due to higher tolerance of alcohol. Prevention should thus target heavy-drinking occasions. Low-volume drinking women without HED and with only little preattendance drinking experienced a high proportion of injuries; such women would be well advised to drink very little or to take other special precautions in risky circumstances.

Attitude changes among emergency department triage staff after conducting routine alcohol screening

Excessive alcohol consumption is common among injury patients, but routine alcohol interventions seem to be difficult to implement in emergency departments. An obstacle seen in previous studies is the limited time available in a real-world setting for staff to participate in routine alcohol screening and interventions. In the present study, ordinary staff participated in a simple alcohol screening procedure. The aim of the study was to evaluate the feasibility of this procedure and if there was any change in attitudes and practices among triage staff after the implementation. We analyzed interviews with six staff members and questionnaires completed by 29 nurses and medical secretaries before and after a period of systematic routine screening. The staff reported that the routine worked well and that few patients reacted negatively. A positive change was seen in attitudes towards alcohol preventive measures in general. However, this seems not to be sufficient for the staff to spontaneously engage more actively. In fact, more of the staff were uncertain after the study period whether the emergency department is an appropriate place for alcohol screening and intervention despite an increased role legitimacy and perceived competence. There is a need for further development of alcohol prevention models that are acceptable for the staff to implement as part of the daily routine.

Toxicology Screening Results: Injury Associations Among Hospitalized Trauma Patients

BACKGROUND

Substance abuse is associated with injuries, but these associations have not been well characterized by type of substance and injury type.

METHODS

A cross-sectional study of patients selected for toxicology screening compared those with positive and those with negative test results for drugs and alcohol.

RESULTS

Patients with positive alcohol toxicology results were more likely to have violence-related and penetrating injuries than patients with negative results. However, after adjustment for positive cocaine toxicology results, the association between alcohol and penetrating injury was no longer significant. Positive test results for any drug were not associated with any specific injury type, but cocaine was independently associated with violence-related injury. The associations of alcohol and cocaine with violence-related injury appear to be additive. In contrast, opiates were independently associated with nonviolent injuries and burns.

CONCLUSIONS

Alcohol and cocaine use is independently associated with violence-related injuries, whereas opiate use is independently associated with nonviolent injuries and burns.

The stages of change questionnaire as a predictor of trauma patients most likely to decrease alcohol use

BACKGROUND

Research has shown that negative trauma-related consequences of drinking can predict readiness to change drinking behavior. These findings are confined to patients with positive blood alcohol levels at admission. The current study extends such findings by examining whether stage of readiness to change among all adult trauma activations admitted to the emergency department for 24 hours or more can be used to predict a change in behavior at followup.

STUDY DESIGN

Patients 18 years of age or older admitted to a Level II trauma center between December 1, 2001, and January 31, 2003, with a trauma activation were eligible to participate. Enrolled patients were screened for alcohol use and readiness to change with the Alcohol Use Disorders Identification Test (AUDIT) and Short Form Stages of Change (SFSC), respectively, within 2 days of discharge. Blood alcohol level (BAL) was obtained for all study patients. Six to 18 months after discharge, patients were followed up with the AUDIT. The ability of the SFSC to predict change in alcohol behavior at followup was analyzed by multiple regression.

RESULTS

Of 253 eligible patients, 146 patients were enrolled and had BAL taken. Most were men (64%) and 36% were women. Mean positive BAL (n = 57) was 186 mg/dL (range 10 to 537 mg/dL). Of these, 23% (13 of 57) met AUDIT criteria for harmful drinking and 47% (27 of 57) met criteria for dependent drinking. Even among those with undetectable BAL (n = 89), harmful or dependent drinking was identified by the AUDIT for 11% (10 of 89). A readiness to change was common among those reporting harmful or dependent drinking (26%) at baseline. The SFSC independently and significantly predicted change in drinking behavior among the 72 patients with followup (p = 0.05). Patients indicating greater readiness to change at baseline were those more likely to decrease their consumption pattern at followup.

CONCLUSIONS

Findings suggest that administering the brief SFSC questionnaire to all trauma patients and providing assistance to those demonstrating a willingness to change may prove to be an effective strategy for reducing problem alcohol use.

Alcohol-Related Expectancies and Assaults Among Injured Drinkers in the Emergency Department Setting

This study examined the extent to which alcohol-related expectancies were associated with assaults among 278 injured drinkers in the emergency department setting. Results of logistic regression analyses indicated that patients who were male, had high blood alcohol levels and who expected alcohol to make them more careless were more likely to report being assaulted. Conversely, among males, patients who expected to become more powerful and aggressive when drinking were less likely to be assaulted. These findings suggest that helping patients understand how expectancies surrounding alcohol use shape drinking and its behavioral concomitants may circumvent their risk for future assaults.

Violence-related injury and intimate partner violence in an urban emergency department

BACKGROUND

To facilitate the identification of ED patients at risk for intimate partner violence (IPV), we assessed the relationship of acute violence-related injury and history of IPV victimization or perpetration.

METHODS

: This cross-sectional study systematically sampled patients presenting to an urban ED. Reason for visit, past year history of IPV victimization and perpetration, alcohol and drug use and abuse, and sociodemographic factors were assessed. We hypothesized that violence-related injury would be positively associated with a history of IPV victimization and with IPV perpetration.

RESULTS

The odds of violence-related injury was increased three-fold among persons with a history of IPV victimization and nearly two-fold (although not statistically significant) among those with IPV perpetration history. Male gender, younger age, and problem drinking were independent risk factors in both models.

CONCLUSION

Screening for IPV among individuals presenting with a violence-related injury may be helpful in identifying individuals at risk of partner violence.

Epidemiology of alcohol and other drug use among motor vehicle crash victims admitted to a trauma center

The objectives of this research were to (1) determine the incidence and prevalence of alcohol and other drug use among motor vehicle crash (MVC) victims admitted to a regional Level-I trauma center, and (2) to examine the utility of using a rapid point-of-collection (POC) drug-testing device to identify MVC patients with drug involvement. Blood and urine specimens were routinely collected per clinical protocol for each MVC victim at the time of admission. Blood alcohol concentration (BAC) levels were determined per standard clinical protocol. Clinical urine specimens were routinely split so that a POC drug-testing device for the detection of commonly abused drugs (Marijuana, Cocaine, Amphetamines, Methamphetamines, and Opiates) could be compared to that of the standard hospital laboratory analysis of each urine specimen (which also included Barbiturates and Benzodiazepines). In the six-month period of this study, nearly two-thirds of trauma center admissions were victims of motor vehicle crashes. During this time, blood and urine was collected from 322 MVC victims. Toxicology results indicated that 59.3% of MVC victims tested positive for either commonly abused drugs or alcohol. More patients tested positive for drug use than tested positive for alcohol, with 33.5% testing positive for drug use only, 15.8% testing positive for alcohol use only, and 9.9% testing positive for both drugs and alcohol. Less than half (45.2%) of the substance-abusing patients in this study would have been identified by an alcohol test alone. After alcohol, marijuana and benzodiazepines were the most frequently detected drugs. Point of collection (POC) test results correlated well with laboratory results and provide important information to initiate rapid intervention/treatment for substance use problems among injured patients.

Behavioral and psychological risk factors for traumatic injury

The objectives of the present study were to determine the behavioral and psychological risk factors associated with injury. The most widely investigated risk factor for injury is alcohol use. However, other behavioral and psychological risk factors may also contribute to injuries. This study examined the association of alcohol use, injury-related risk behaviors, and psychological characteristics with injury status. A hospital-based case control study of 177 patients admitted for treatment of traumatic injury, and 195 general surgery patients as controls, was conducted. Alcohol use, injury-related risk behaviors, impulsivity, sensation seeking, and risk perception were assessed. The results from a multivariate analysis controlling for age, gender, and ethnicity indicated that, in addition to alcohol consumption (OR = 2.2, 95% CI = 1.1-4.5), driving (OR = 2.4, 95% CI = 1.7-3.5) and violence-related risk behaviors (OR = 1.6, 95% CI = 1.0-2.2) are significantly associated with injury. In conclusion, the engagement in injury-related risk behaviors, including alcohol use, is strongly associated with injury status. Brief interventions that directly address these behavioral risk patterns in injured patients may reduce their risk of future injury.

The Causal Attribution of Injury to Alcohol Consumption: A Cross-National Meta-Analysis From the Emergency Room Collaborative Alcohol Analysis Project

BACKGROUND

Whereas a substantial literature exists documenting the association of alcohol and injuries, causal associations are less well established.

METHODS

The relationship of drinking-in-the-event variables with attributing a causal association of alcohol consumption and the injury event was examined by using meta-analysis across 13 emergency room studies from 8 countries included in the Emergency Room Collaborative Alcohol Analysis Project.

RESULTS

Pooled odds ratios for both log-transformed blood alcohol concentration at the time of the emergency room visit and the amount of alcohol consumed in the 6 hr before injury were positively predictive (1.19 and 1.80, respectively) and heterogeneous across studies. Effect size changed little when age and gender were controlled. When stratifying on reporting five or more drinks on an occasion during the last year (5+ yearly drinkers), the amount consumed was positively predictive of reporting a casual association of drinking and injury only for 5+ yearly drinkers. The effect size of feeling drunk at the time of injury, controlling for the amount of alcohol consumed, was positively predictive (2.04) but heterogeneous across studies. Meta-analysis regression found the level to which alcohol is consumed in a detrimental pattern to be a significant predictor of blood alcohol concentration, and of the amount consumed and feeling drunk at the time of injury, on causal attribution, with a lower detrimental pattern level with a larger effect size.

CONCLUSIONS

The association of acute use of alcohol on causal attribution may be affected by chronic use to some extent, but this association is negatively affected by the degree to which a society exhibits harmful drinking patterns.

The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview

AIMS

As part of a larger study to estimate the global burden of disease attributable to alcohol: to quantify the relationships between average volume of alcohol consumption, patterns of drinking and disease and injury outcomes, and to combine exposure and risk estimates to determine regional and global alcohol-attributable fractions (AAFs) for major disease and injury categories. DESIGN, METHODS, SETTING: Systematic literature reviews were used to select diseases related to alcohol consumption. Meta-analyses of the relationship between alcohol consumption and disease and multi-level analyses of aggregate data to fill alcohol-disease relationships not currently covered by individual-level data were used to determine the risk relationships between alcohol and disease. AAFs were estimated as a function of prevalence of exposure and relative risk, or from combining the aggregate multi-level analyses with prevalence data.

FINDINGS

Average volume of alcohol consumption was found to increase risk for the following major chronic diseases: mouth and oropharyngeal cancer; oesophageal cancer; liver cancer; breast cancer; unipolar major depression; epilepsy; alcohol use disorders; hypertensive disease; hemorrhagic stroke; and cirrhosis of the liver. Coronary heart disease (CHD), unintentional and intentional injuries were found to depend on patterns of drinking in addition to average volume of alcohol consumption. Most effects of alcohol on disease were detrimental, but for certain patterns of drinking, a beneficial influence on CHD, stroke and diabetes mellitus was observed.

CONCLUSIONS

Alcohol is related to many major disease outcomes, mainly in a detrimental fashion. While average volume of consumption was related to all disease and injury categories under consideration, pattern of drinking was found to be an additional influencing factor for CHD and injury. The influence of patterns of drinking may be underestimated because pattern measures have not been included in many epidemiologic studies. Generalizability of the results is limited by methodological problems of the underlying studies used in the present analyses. Future studies need to address these methodological issues in order to obtain more accurate risk estimates.

Characteristics of intoxicated trauma patients

Of 1320 patients who were hospitalized for injuries, a total of 315 were known to be intoxicated with alcohol at the time of trauma. A retrospective chart review was performed to determine which biopsychosocial markers correlated with increasing severity of alcohol use disorders in a sample of 184 (58.4%) of these 315 patients. Markers associated with increased severity were: an increased mean corpuscular volume (MCV; p = 0.007), previous legal problems (p = 0.023), previous alcohol rehabilitation (p < 0.001), previous attendance at self-help meetings (p < 0.001), admitting to having an alcohol problem (p < 0.001), and a willingness to change drinking behavior (p < 0.001). Routine toxicology screening tests, simple questions about previous alcohol or drug abuse treatment, and direct questions about the patient's own perception of the severity of disease and readiness to change drinking behavior can identify many victims of major trauma who could potentially benefit from a referral for alcohol rehabilitation.

The influence of extrinsic and intrinsic risk factors on the probability of sustaining an injury

This study was designed to quantify the relative contributions of extrinsic and intrinsic risk factors to the probability of an injury event. A case-control design was used with data collected from injured patients at an emergency department (n=797) and a community sample matched on area of residence and time of injury (n=797). Principal components analysis was used to develop scales for the measurement of 'intrinsic' risk taking tendencies that were slightly modified versions of previously published measures. Two principal components were identified: 'health risk taking' (HRT) and 'adventurous risk taking' (ART). Logistic regression analysis identified variables that significantly predicted membership of the group of injured cases. The main hypothesis was supported by the results: that 'extrinsic' factors such as location, activity, drug and alcohol use and the type of people present at the time of the injury were related to a greater risk of injury than 'intrinsic' variables (health and adventurous risk taking tendencies). The results suggest that injury research and prevention efforts should continue to focus on the identification and modification of situational risk factors for injury rather developing programs that focus on high-risk individuals. High-risk alcohol use, use of prescribed drugs and aspects of work and recreational environments were identified as warranting particular attention.

A randomized controlled trial of a brief intervention after alcohol-related facial injury

AIM

To evaluate the effectiveness of a brief motivational intervention on alcohol consumption and misuse in young males with alcohol-related face injury.

DESIGN

Randomized controlled trial.

SETTING

Oral and maxillofacial surgery out-patient clinic in an urban teaching hospital.

PARTICIPANTS

One hundred and fifty-one participants were randomized to motivational intervention and control conditions.

INTERVENTIONS

Control was treatment as usual. The intervention was treatment as usual plus a one-session brief motivational intervention administered by a nurse.

MEASUREMENTS

Three sets of measurements were taken at baseline, 3-month and 1-year follow-up. Collateral measurements were also taken at 1-year follow-up. Primary outcome measures were total alcohol consumption, typical weeks consumption and days abstinent in preceding 3 months. Other outcome measures included the Alcohol Use Disorders Identification Test, a short form of the Alcohol Problems Questionnaire, and a measure of satisfaction with social relationships.

RESULTS

There was a significant decrease in 84-day total alcohol consumption across the year (P < 0.006) and further, a significant effect for the motivational intervention was demonstrated (P < 0.029). This pattern was repeated for days abstinent and alcohol consumption in a typical week as well as alcohol-related problems. There was a significantly greater reduction in the percentage of hazardous drinkers in the motivational intervention group (from 60% to 27%, P < 0.009) compared to the control group (from 54% to 51%, NS).

CONCLUSION

A proportion of young men change their alcohol consumption following alcohol-related injury. A nurse-led psychological intervention adds significantly to the proportion and magnitude of response.

Improving emergency medicine residents' approach to patients with alcohol problems: a controlled educational trial

STUDY OBJECTIVE

We determine whether training using a structured skills-based intervention would improve emergency medicine residents' knowledge and practice in screening and intervening with patients presenting to the emergency department with alcohol problems.

METHODS

In a controlled trial conducted at 2 similar emergency medicine residency programs associated with urban, Level I trauma centers, a 4-hour didactic, video, and skills-based workshop was conducted. Main outcome measures included (1) scores on changes in self-reported knowledge, current practice, self-efficacy, role-responsibility, attitudes and beliefs, and provider readiness to change from baseline to 1 year after intervention and (2) change in practice as measured by record review before and after intervention.

RESULTS

The intervention group (n=17) had a significant increase in knowledge scores (P <.001) and practice with regard to percent of medical records with evidence of screening and intervention (17% before versus 58% after; 95% confidence interval [CI] 31 to 50; P <.001); no change was observed in the control group (n=19). These increases were significantly different between groups (95% CI 30 to 54; P <.001). There were no significant differences within or between groups for composite scores derived for current practice, self-efficacy, role responsibility, or readiness to change.

CONCLUSION

A brief, structured, educational intervention for residents contributed to significant improvement in knowledge and practice with regard to patients with alcohol problems.

Concepts and items in measuring social harm from drinking

Social epidemiological traditions of asking about problems related to drinking are considered. The issue of the attribution of the problem to drinking, and variations in formulations concerning this, are discussed. Social problems from drinking are inherently properties of social interactions, so that they are composed both of behaviour deemed problematic and of a reaction by another. Most items measuring social harm asked of the drinker him/herself are concerned with major social roles, and problems in the particular life area of the role (work, family, friendships, etc.). Some ask the respondent to attribute the problems to alcohol, some ask about others' attributions to alcohol, and some ask about "objective" problem indicators, although these usually have the respondent's attribution to drinking built in. The possibility of a more systematic way of covering different aspects of interactional problems, as reported by the drinker, is considered. Traditions of questioning the person on the other side of the interaction--i.e., items about others' troubles with drinking, and the effect of these on the respondent--are also discussed, and possibilities for bringing questions asked of the drinker and questions asked of interacting others into the same frame are considered.

Association of alcohol use and other high-risk behaviors among trauma patients

BACKGROUND

Risk behaviors and psychological problems may limit recovery after trauma, may be related to injury recidivism, and may limit the effectiveness of alcohol interventions in trauma patients. The aim of the current study was to evaluate the prevalence of behaviors associated with injury and their relationship with alcohol use in adult trauma patients.

METHODS

A prospective cohort of 301 adult patients admitted to a single Level I trauma center were interviewed regarding risk behaviors and alcohol use.

RESULTS

There was evidence of acute and/or chronic alcohol use in 48.2% of cases. Over three fourths of patients (77%) engaged in one or more high-risk driving practices, 40% engaged in one or more violence-related behaviors, and 19% reported suicidal ideation in the last year. These risk behaviors were more common in patients who evidenced acute and/or chronic alcohol use.

CONCLUSION

Behaviors that place an individual at greater risk for traumatic injury are common among seriously injured adult patients admitted to an urban Level I trauma center and frequently coexist with alcohol use. Their importance to injury, injury recidivism, and recovery after trauma requires further investigation.