Journal Article Annotations
2020, 2nd Quarter
Annotations by Scott Simpson, MD, MPH
PUBLICATION #1 — Emergency Psychiatry
The investigators prospectively identified emergency department (ED) patients with gastrointestinal (GI) symptoms of unknown etiology and screened them for cannabinoid hyperemesis syndrome (CHS) based on previously published diagnostic criteria. CHS comprised 1.6% of all unknown GI somatic complaints. CHS had longer median lengths of ED stay compared to other GI patients (12h v 6h, p=.04), more often left the ED against medical advice (8% v 4%, p=.03), and often required medication treatment in the ED—10% received opioids.
Strengths and weaknesses
Despite cannabis being illegal in the area of the study, the investigators identified a large cohort of patients with CHS and, for the first time, describe the adverse impacts of CHS on the course of emergency care. Applications of the CHS diagnosis was rigorous. The authors reported seeking to ascertain more data from patients after discharge, but these results are not reported; most likely, they could not retain a sufficient number of patients in the study. There was a large percentage of patients who did not complete the study questionnaire, and the study certainly underestimates the prevalence of CHS in the ED population.
This study is the first to report a large cohort of CHS patients in the emergency setting. The condition is associated with significant rates of adverse events, including leaving against medical advice and longer ED stays. This report also reminds of of the high prevalence of medically unexplained symptoms in the ED. While 1.6% of unexplained GI symptoms in the ED were found to likely be CHS, the other 98-odd percent remained…unexplained.
Type of study
(http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401) prospective cohort study
The investigators describe a series of 724 university students who presented to the psychiatric emergency service (PES) in a college town over 4 years. There were an increasing number of visits over time. Black students were two times more likely to present than students of other backgrounds relative to the composition of the college’s study body. Female students were more likely to endorse depression, while male students more often reported bipolar disorder. Male students more often presented via police. International students were more likely to report a lifetime history of suicide attempts. A high proportion of students were hospitalized (35%), about half of those involuntarily.
Strength and weaknesses
The chart abstraction methods were rigorous and well-described—multiple reviews coded each chart, and inter-rater reliability was strong. The inclusion of all presentations limits bias in interpreting results. The most significant limitations are that this study included only one PES in a single town and that authors did not review patients with lower acuity presentations seen outside the PES in the medical emergency department. Thus, these students likely represent the most serious mental health presentations that were too acute for outpatient walk-in clinics or general ED care.
University students represent a growing number of emergency psychiatric visits, and there are unique risk factors for psychiatric crisis and access to care and social support among this population. Significant variations in presentations existed between male and female student, and international students may pose unique concerns. Emergency psychiatrists should be cognizant of care options for these students in their communities and pro-actively engage student mental health services.
Type of study
(http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401) case series