This work informs both future retrospective research that requires identification of this patient population, as well as potential future prospective work to identify and intervene on these patients in real time. Future integration of semantic types with ED discharge diagnoses could allow for automation of this process in real time, building the foundation for decision support systems that guide providers to avoid SBDs or to provide additional assistance to patients discharged with a SBD. Our analysis was limited to a single academic institution that uses a single EHR. Our implementation design includes ICD-10 codes associated with clinical diagnoses made in the ED; however, other hospital systems may use other medical terminologies or proprietary diagnosis dictionaries. The UMLS allows for various search modes, including various terminologies, ontologies and search terms; however, a comparison of these methods is needed to ensure reliable results. In addition, even among institutions using similar EHRs and impressions mapped to ICD-10, there are likely to be health system and regional variation in practice patterns for the level of detail provided at the time of discharge , which may make these methods less reliable. For the purpose of this analysis we used the first diagnosis and associated ICD-10 code assigned to each patient encounter,microgreen rack for sale which is defined as the “primary clinical impression” in our EHR. We presume that the “primary clinical impression” is the diagnosis made by the treating provider most closely associated with the patient’s encounter. The analysis of additional diagnoses assigned at the time of treatment and the development of a process to weigh the value of combinations of SBDs and non-SBDs were outside the scope of this research.
It is possible that if a patient was assigned additional diagnoses that were not SBDs, their overall level of uncertainty could be lower or vice-versa. Further analysis will have to be performed to include additional diagnosis codes and develop a process to determine the level of uncertainty associated with combinations of SBDs and non-SBDs. Also, we mapped ICD-10 codes to the first CUI returned by the UMLS. It is possible that additional CUIs could be more appropriate in certain cases, although an analysis to compare various CUIs would deviate significantly from the simple methods described in this manuscript. We used manual review and categorization of discharge diagnoses by two emergency physicians as the gold standard for SBDs. While our reviewers had high inter-rater reliability , they were not blinded to the goals of the study, and may have been biased in their categorization of SBDs. Additionally, as noted above, some of these discharge diagnoses are inherently ambiguous. Our team of raters established the list of SBDs via consensus and in these ambiguous cases attempted to consider the case from the viewpoint of the patient. For example, if a patient presents with pain in a limb, they are often concerned about a fracture or sprain; in this case, receiving a diagnosis of musculoskeletal pain has more specificity than the presenting complaint of “leg pain.” In contrast, when a patient presents unable to urinate and is discharged with a diagnosis of “urinary retention,” they have gained no specificity beyond that with which they presented. It was this sort of rationale that informed our decision-making and why “musculoskeletal pain” is not considered a SBD, but “urinary retention” is. However, despite our high inter-rater agreement, we acknowledge that others, including both patients and medical professionals, may disagree with our determination of SBD classification. Future work is needed to refine this method before routine use to identify complete cohorts of patients or to assess frequencies of occurrence. Further, by categorizing SBDs, we are not attempting to assign value to the SBD or encouraging emergency physicians to provide definitive diagnoses in all cases, as the physician’s role is to rule out immediately dangerous conditions rather than provide a definitive diagnosis.
Finally, per our research protocol we excluded pregnant and pediatric patients; however, these patients could also benefit from SBD research and future methods should consider including these populations. Cocaine and amphetamines have different mechanisms of action but similarly affect monoamine transporters. Cocaine blocks the reuptake of neurotransmitters, while amphetamine releases more into the synapse.Therefore, when comparing the two drugs, methamphetamine affects dopamine balance in the brain for a longer period of time. This is one of the many factors that have led to the differential effects of these stimulants.In recent years, there has been an increase in overall prescriptions to college students, especially to those in academically stressful situations.Misuse of stimulants has been shown to cause multiple issues including tissue ischemia and long-term neurological changes. An apparent correlation has been observed between the increase in overall stimulant prescription to patients of varying ages and demographics and misuse of these stimulants, resulting in both physiological and neurological changes that could be prevented.Particularly, the neurological changes that result from stimulant abuse may increase their risk of suicide. Globally, suicide is the third leading cause of death in the 15-44 age group.6 Although a strong correlation between stimulant abuse induced neurological changes and suicide exists, various other factors contribute to the onset of suicidal thoughts. The rising concern with regard to impulsive suicidal thoughts, and their potential to claim lives, has spurred public health intervention efforts to provide support to these most vulnerable and at risk populations. Public health interventions in populations suffering from stimulant abuse can facilitate a reduction of suicide attempts in this demographic.Specific, targeted preventive efforts may reduce SAT in at-risk populations and help maintain mental and physiological health. An association between stimulant abuse and SAT has already been reported.We expanded on this work, accessing the 2011 State Emergency Department Database to determine which subgroups, if any, of stimulant-abuse populations are at increased risk of SAT.
This subgroup analysis may inform targeted public health efforts focused on the most at-risk individuals. Analysis of over 10 million ED visits in California gave us insight into the relation between SAT and stimulant abuse in different patient populations. Our findings cohere with previous findings and indicate that depressed or suicidal individuals are more likely to abuse stimulants and are increasingly susceptible to SAT. As the only modifiable risk factor in our study,cannabis grow facility layout stimulant abuse was more common in young and middle-aged, male, Native American, and Black patients with lower household income. We also found that stimulant abuse puts females at higher risk of SAT. The risk of SAT is prevalent across patient populations and increases with factors such as stimulant abuse.Not only does a SAT endanger the life of a vulnerable individual, it also psychologically affects the individual, families, communities, and society as a whole. The substantial impact that suicide has on the community necessitates public health intervention efforts to target high-risk populations. Young populations have been deemed increasingly at risk of suicide due to a variety of psychosocial stressors.Research stipulates that within these diverse, young populations, females have proven to be the most vulnerable group.Suicide remains the second leading cause of death in individuals between the ages of 10- 34.Stimulant abuse contributes to the numerous stressors that young populations face.Public health prevention efforts within this demographic group may reduce the economic and human cost of suicide. The rising national trend in non-medical prescription stimulant abuse has allowed experts to discern the psychological factors that contribute to the start of recreational substance consumption.This work indicates that the initiation of abuse often follows discrete traumatic events.Therefore, the inefficiency of prescription medication as a coping mechanism may be attributed to these higher suicidal rates. A prominent correlation between lower median household income state quartile and increased stimulant abuse exists . Poor access to healthcare and high rates of depression in individuals of lower socioeconomic status contribute to psychological effects prompting non-medical stimulant abuse.Non-medical stimulant use has also been associated with other harmful habits including tobacco, alcohol, and other illicit drug use.Each of these habits has also been correlated to increased suicide risk, all of which may be contributing factors.Multi-variable analysis showed SAT is associated with stimulant abuse and younger age. One potential reason for this result may involve the absence of impulse control correlated with drug abuse.Meanwhile, the proportion of ED visits with associated stimulant abuse was higher in younger age groups. This pattern corroborates past research indicating increased non-medical stimulant use among college populations.4 Association of SAT with stimulant abuse , and higher prevalence of stimulant abuse in those who are younger in age indicates that young people should be targeted for active stimulant-abuse prevention and treatment interventions. We found a stronger association between SAT and stimulant abuse in females, in all age groups. Previous literature coheres with this finding.
Women have been known to undergo the telescoping effect, which stipulates that in the long term, females escalate from low-dose use to addiction faster than men.The quicker increase in consumption rates has been attributed to hormonal fluctuations inherent with the menstrual cycle. This hormonal fluctuation has been shown to subject women to differential drug effects dependent on their menstrual phase.Women have been shown to be significantly more susceptible to physiological dependence, which is the most extreme classification of drug use in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. This is associated with an increase in extreme lifestyle changes attributable to drug administration and consumption.Suicide attempts are associated with Native American and White race. At the same time, stimulant abuse was more common in Native American, and to a lesser extent, White patients. This pattern indicates active stimulant-abuse prevention and treatment interventions could specifically reduce SAT in those racial groups. It has been well established in the literature that race plays a significant role in the type of substance being abused.The increased rate of cocaine abuse in Black populations has been attributed to distribution networks and the historic, structurally driven prevalence of cocaine in Black communities.White and Hispanic populations, on the other hand, have more commonly used amphetamines or are considered dual users of both stimulants.Interestingly, Asian/Pacific Islanders have also experienced a sharp increase in non-cocaine stimulant admissions to treatment centers.We were not able to differentiate the exact type of the stimulant in this study.Anthropology has not been disposed toward addressing cutting as a problematic cultural or clinical phenomenon given the disciplinary propensity to understand body mutilation and modification in terms of rituals and cultural practices. This is perhaps because ritual meaning is not so dependent on distinguishing whether harm is inflicted by others or by oneself or on differentiating cultural practice from psychopathology. One other anthropological observation has been provided by Lester, who notes that current explanations of self-harm can be grouped into four categories: communicating emotional pain, emotional or physiological self-regulation, interpersonal strategy, and cultural trend. She notes that these categories share the idea that self-harm manifests individual pathology or dysfunction, with the cultural assumption of the individual as a rational actor. In contrast, an anthropological perspective emphasizes the “cultural actor who embodies and responds to cultural systems of meaning to internal psychological or physiological states” . Emphasizing the powerful symbolic significance and long cross-cultural record of self-harm and blood shedding as ritual and even therapeutic practices, she suggests that contemporary cutting may be seen as privatized and decontextualized social rituals affecting transformation parallel to collective initiation rituals that operate in a cycle of self-harm and repair, especially in the case of adolescent girls struggling with the aftermath of sexual abuse and/or with contradictory gender messages . Sociocultural characteristics of a typical “self-cutter” emerged in the 1960s as Euro-American, attractive, intelligent, and possibly sexually adventurous teenage girls, that Brickman claimed was partially taken up in medical discourse in a manner that “pathologizes the female body, relying on the notion of ‘femininity as a disease’” . Gilman took exception to assumptions of pathology with the provocative claim that “self-cutting is a reasonable response to an irrational world” . From a clinical vantage point, self-cutting is often viewed as a type of injury or harm to the self. The historical backdrop to this development can be traced to Menninger’s attention to self-mutilation as distinguished from suicidality. The distinction between “delicate” and “coarse” self-cutting was made by Pao , with Weissman focusing on wrist-cutting syndrome and Pattison and Kahan proposing the existence of a deliberate self-harm syndrome.