2286Clinical correlates and outcomes of methamphetamine-associated cardiovascular disease among hospitalised patients in California

Background

Methamphetamine abuse is a growing public health crisis, affecting an estimated 33 millions users worldwide. It is associated with the development of several cardiac pathologies, however the incidence and predictors of cardiovascular disease among methamphetamine users remains unclear.

Purpose

We aim to describe the clinical characteristics of methamphetamine users identified from a large cohort of hospitalised patients. Through comparison of methamphetamine users who develop cardiovascular disease (CVD) with those who do not, we aim to identify predictors of these cardiac conditions.

Methods

We studied the clinical and sociodemographic characteristics (via ICD-9 codes) of methamphetamine users using a database of hospitalised patients in California, captured by the Healthcare Cost and Utilization Project (HCUP) between 2005–2011. We used Cox proportional hazards model for incidence of methamphetamine-associated cardiac pathologies (pulmonary hypertension, congestive heart failure, stroke and myocardial infarction) among methamphetamine users.

Results

Amongst 20,249,026 persons in HCUP, we identified n=66,199 patients as methamphetamine users. Methamphetamine users were younger (33±11.6 years) and more frequently male (63.3%) when compared to non-users (45±19.5 years, 44.4% male). They were also more likely to smoke (26% vs 4%) and concurrently abuse alcohol (7% vs 1%).

Methamphetamine use was associated with a 32% increased risk of CVD (HR 1.32, CI 1.26–1.38); higher than those who abuse alcohol (HR 1.28, CI 1.27–1.38), but lower than in those who abuse cocaine (HR 1.47, CI 1.40–1.54), when compared to non-users. Of the 4 CVD types studied, methamphetamine use was most strongly associated with the development of congestive heart failure (HR 1.53) and pulmonary hypertension (HR 1.42). Whilst male gender (HR 1.73) was a significant predictor of myocardial infarction among methamphetamine users, female gender was not found to be a significant risk factor for the development of any of the studied pathologies. Chronic Kidney Disease (HR 2.38, CI 1.74–3.25) and hypertension (HR 2.26, CI 2.03–2.51) were the risk factors most strongly associated with development of CVD among methamphetamine users.

A Kaplan-Meier plot was constructed (figure 1), comparing the time-to-event for development of CVD among users of either methamphetamine, alcohol or cocaine, with non-users. Methamphetamine and cocaine users both had a higher incidence of CVD after 5 years, when compared to those who abuse alcohol only.

Conclusions

Methamphetamine users are at increased risk of CVD when compared to the general hospitalised population. They have a similar risk of CVD as users of cocaine and a higher risk than those who abuse alcohol. Whilst male gender appears to be a risk factor for myocardial infarction among methamphetamine users, there was no significant association found between female gender and the development of CVD in this population.

Mandatory reporting of domestic violence injuries to the police: what do emergency department patients think?

CONTEXT

Laws requiring mandatory reporting of domestic violence to police exist in 4 states. Controversy exists about the risks and benefits of such laws.

OBJECTIVE

To examine attitudes of female emergency department patients toward mandatory reporting of domestic violence injuries to police and how these attitudes may differ by abuse status.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional survey conducted in 1996 of 1218 women patients (72.8% response rate) in 12 emergency departments in California (a state with a mandatory reporting law) and Pennsylvania (without such a law).

MAIN OUTCOME MEASURES

Opposition to mandatory reporting to police and the characteristics associated with this belief.

RESULTS

Twelve percent of respondents (n = 140) reported physical or sexual abuse within the past year by a current or former partner. Of abused women, 55.7% supported mandatory reporting and 44.3% opposed mandatory reporting (7.9% preferred that physicians never report abuse to police and 36.4% preferred physicians report only with patient consent). Among nonabused women, 70.7% (n = 728) supported mandatory reporting and 29.3% opposed mandatory reporting. Patients currently seeing/living with partners (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.0), non-English speakers (OR, 2.1; 95% CI, 1.4-3.0), and those who had experienced physical or sexual abuse within the last year (OR, 2.2; 95% CI, 1.6-2.9) had higher odds of opposing mandatory reporting of domestic violence injuries. There were no differences in attitudes by location (California vs Pennsylvania).

CONCLUSIONS

The efficacy of mandatory reporting of domestic violence to police should be further assessed, and policymakers should consider options that include consent of patients before wider implementation.

An evaluation of a system-change training model to improve emergency department response to battered women

OBJECTIVES

To evaluate a system-change model of training from the Family Violence Prevention Fund and the Pennsylvania Coalition Against Domestic Violence for improving the effectiveness of emergency department (ED) response to intimate partner violence (IPV).

METHODS

An experimental design with outcomes measured at baseline, 9-12, and 18-24 months post-intervention. Twelve hospitals in Pennsylvania and California with 20,000-40,000 annual ED visits were randomly selected and randomly assigned to experimental and control conditions. Emergency department teams (physician, nurse, social worker) from each experimental hospital and a local domestic violence advocate participated in a two-day didactic information and team planning intervention.

RESULTS

The experimental hospitals were significantly higher than the control hospitals on a staff knowledge and attitude measure (F = 5.57, p = 0.019), on all components of the "culture of the ED" system-change indicator (F = 5.72, p = 0.04), and in patient satisfaction (F = 15.43, p < 0.001) after the intervention. There was no significant difference in the identification rates of battered women (F = 0.411, p = 0.52) (although the linear comparison was in the expected direction) in the medical records of the experimental and control hospitals.

CONCLUSIONS

A system-change model of IPV ED training was effective in improving staff attitudes and knowledge about battered women and in protocols and staff training, as well as patient information and satisfaction. However, change in actual clinical practice was more difficult to achieve and may be influenced by institutional policy.

Ocular decompression retinopathy after resolution of acute primary angle closure glaucoma

A patient presented with acute primary angle closure glaucoma with markedly elevated intraocular pressure. Two weeks after laser peripheral iridotomy and resolution of the acute attack, the patient was noted to have developed scattered retinal haemorrhages. The haemorrhages resolved over time with no visual sequelae. This is the first reported case of ocular decompression retinopathy after resolution of acute primary angle closure glaucoma.

Prevalence of intimate partner abuse in women treated at community hospital emergency departments

CONTEXT

The majority of prior studies examining intimate partner abuse in the emergency department (ED) setting have been conducted in large, urban tertiary care settings and may not reflect the experiences of women seen at community hospital EDs, which treat the majority of ED patients in the United States.

OBJECTIVE

To determine the prevalence of intimate partner abuse among female patients presenting for treatment in community hospital EDs and describe their characteristics.

DESIGN

An anonymous survey conducted from 1995 through 1997 inquiring about physical, sexual, and emotional abuse.

SETTING

Eleven community EDs in Pennsylvania and California.

PARTICIPANTS

All women aged 18 years or older who came to the ED during selected shifts.

MAIN OUTCOME MEASURES

Reported acute trauma from abuse, past-year physical or sexual abuse, and lifetime physical or emotional abuse.

RESULTS

Surveys were completed by 3455 (74%) of 4641 women seen. The prevalence of reported abuse by an intimate partner was 2.2% (95% confidence interval [CI], 1.7%-2.7%) for acute trauma from abuse, 14.4% (95% CI, 13.2%-15.6%) for past-year physical or sexual abuse, and 36.9% (95% CI, 35.3%-38.6%) for lifetime emotional or physical abuse. California had significantly higher reported rates of past-year physical or sexual abuse (17% vs 12%, P<.001) and lifetime abuse (44% vs 31%, P<.001) than Pennsylvania. Logistic regression modeling identified 4 risk factors for reported physical, sexual, or acute trauma from abuse within the past year: age, 18 to 39 years (odds ratio [OR], 2.2; 95% CI, 1.7-3.0); monthly income less than $1000 (OR, 1.7; 95% CI, 1.3-2.1); children younger than 18 years living in the home (OR, 2.0; 95% CI, 1.5-2.6); and ending a relationship within the past year (OR, 7.0; 95% CI, 5.5-8.9).

CONCLUSION

If the prevalence of abuse in community hospitals throughout the United States is similar to the range of prevalence estimates found in this study, then heightened awareness of intimate partner abuse is warranted for patients presenting to the ED.