1
|
Paroz S, Monnat M, Panese F, Saraga M, Daeppen JB. Caring for patients with substance use disorders: a qualitative investigation of difficulties encountered by hospital-based clinicians. J Addict Dis 2023:1-12. [PMID: 37369578 DOI: 10.1080/10550887.2023.2227307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Background: Caring for patients with substance use disorders (SUD) is held in low regard and many clinicians resist treating them. To address this situation, numerous research projects assessed training program gaps and professional attitudes. In contrast, this study explored the actual clinical difficulties that a variety of hospital-based professionals encounter when treating patients with SUD. Methods: Qualitative multiple method design including: (1) individual semi-structured interviews with SUD experts and educators; (2) video-elicited, cross self-confrontation interviews with clinicians working in a specialist addiction unit; (3) paired semi-structured interviews with clinicians working in non-specialist units. Participants were recruited within one university hospital. Data collected at stages (1) and (3) relied on an interview guide and were analyzed using conventional content analyses. Data collected at stage (2) consisted of discussions of video recorded clinical interviews and were analyzed based on a participatory approach. Results: Twenty-three clinicians from seven hospital units participated. Forty-four difficulties were reported that we classified into six categories: knowledge-based; moral; technical; relational; identity-related; institutional. We identified seven cross-category themes as key features of SUD clinical complexity: exacerbation of patient characteristics; multiplication of medical issues; hybridity and specificity of medical discipline; experiences of stalemate, adversity, and role reversal. Conclusions: Our study, providing a comprehensive analysis of the difficulties of caring for patients with SUD, reveals a highly challenging clinical practice for a diversity of healthcare providers. They represent a complementary approach to addressing resistance as an important feature of a complex clinical system, and valuable material to discussing professional preparedness.
Collapse
Affiliation(s)
- Sophie Paroz
- Service of Addictions Medicine, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
| | - Martine Monnat
- Service of Community Psychiatry, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
- Public Health Service of Canton de Vaud, Department of Health and Social Action, Canton of Vaud, Lausanne, Switzerland
| | - Francesco Panese
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
- Institute of Social Sciences, University of Lausanne, Canton of Vaud, Switzerland
| | - Michael Saraga
- Service of General Psychiatry, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
| | - Jean-Bernard Daeppen
- Service of Addictions Medicine, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
| |
Collapse
|
2
|
Romero-Rodríguez E, Amezcua-Prieto C, Morales Suárez-Varela M, Ayán-Pérez C, Mateos-Campos R, Martín-Sánchez V, Ortíz-Moncada R, Redondo-Martín S, Alguacil Ojeda J, Delgado-Rodríguez M, Blázquez Abellán G, Alonso-Molero J, Cancela-Carral JM, Valero Juan LF, Fernández-Villa T. Patterns of Alcohol Consumption and Use of Health Services in Spanish University Students: UniHcos Project. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:6158. [PMID: 35627695 PMCID: PMC9141368 DOI: 10.3390/ijerph19106158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/10/2022] [Accepted: 05/16/2022] [Indexed: 11/28/2022]
Abstract
The aim of the study was to examine the association of alcohol consumption patterns (hazardous alcohol use and binge drinking) and the use of emergency services and primary care consultations in university students. An observational, descriptive, cross-sectional study was conducted at eleven Spanish universities collaborating within the uniHcos Project. University students completed an online questionnaire that assessed hazardous alcohol use and binge drinking using the AUDIT questionnaire and evaluated the use of emergency services and primary care. A descriptive analysis of the data was performed, as well as the chi-squared test and Student’s t-test and nonconditional logistic regression models to examine this association. Results: There were 10,167 participants who completed the questionnaire. The prevalence of hazardous alcohol use was 16.9% (95% CI: 16.2−17.6), while the prevalence of binge drinking was 48.8% (95% CI: 47.9−49.8). There were significant differences in the use of emergency services in those surveyed with hazardous alcohol use (p < 0.001) or binge drinking pattern (p < 0.001). However, no significant differences were observed in terms of attendance during primary care visits in individuals with hazardous alcohol use (p = 0.367) or binge drinking pattern (p = 0.755). The current study shows the association between university students with a pattern of hazardous alcohol use or binge drinking and greater use of emergency services. However, no significant association was observed between the said consumption patterns and the use of primary care services.
Collapse
Affiliation(s)
- Esperanza Romero-Rodríguez
- Maimonides Biomedical Research Institute, Reina Sofia University Hospital, University of Córdoba, 14001 Cordoba, Spain;
| | - Carmen Amezcua-Prieto
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), 28029 Madrid, Spain; (C.A.-P.); (M.M.S.-V.); (V.M.-S.); (M.D.-R.)
- Department of Preventive Medicine and Public Health, University of Granada, 18016 Granada, Spain
| | - María Morales Suárez-Varela
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), 28029 Madrid, Spain; (C.A.-P.); (M.M.S.-V.); (V.M.-S.); (M.D.-R.)
- Department of Preventive Medicine and Public Health, Food Sciences, Toxicology and Legal Medicine, University of Valencia, 46100 Valencia, Spain
| | - Carlos Ayán-Pérez
- Well-Move Research Group, Department of Special Didactics, University of Vigo, 36310 Vigo, Spain;
| | - Ramona Mateos-Campos
- Area of Preventive Medicine and Public Health, University of Salamanca, 37007 Salamanca, Spain; (R.M.-C.); (L.F.V.J.)
| | - Vicente Martín-Sánchez
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), 28029 Madrid, Spain; (C.A.-P.); (M.M.S.-V.); (V.M.-S.); (M.D.-R.)
- Department of Biomedical Sciences, University of León, 24071 León, Spain
- The Research Group in Gene-Environment and Health Interactions, Institute of Biomedicine (IBIOMED), University of León, 24071 León, Spain
| | - Rocío Ortíz-Moncada
- Public Health Research Group, Food and Nutrition Research Group, University of Alicante, 03550 Alicante, Spain;
| | - Susana Redondo-Martín
- Department of Preventive Medicine and Public Health, University of Valladolid, 47005 Valladolid, Spain;
| | - Juan Alguacil Ojeda
- Department of Clinical and Experimental Psychology, University of Huelva, 21071 Huelva, Spain;
| | - Miguel Delgado-Rodríguez
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), 28029 Madrid, Spain; (C.A.-P.); (M.M.S.-V.); (V.M.-S.); (M.D.-R.)
- Department of Health Sciences, University of Jaén, 23071 Jaén, Spain
| | - Gemma Blázquez Abellán
- Department of Medical Sciences, School of Pharmacy, University of Castilla-La Mancha, 02008 Albacete, Spain;
| | - Jéssica Alonso-Molero
- Department of Preventive Medicine and Public, University of Cantabria-IDIVAL, 39008 Santander, Spain;
| | - José María Cancela-Carral
- Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36312 Vigo, Spain;
- Department of Specials Didactics, University of Vigo, 36310 Vigo, Spain
| | - Luis Félix Valero Juan
- Area of Preventive Medicine and Public Health, University of Salamanca, 37007 Salamanca, Spain; (R.M.-C.); (L.F.V.J.)
| | - Tania Fernández-Villa
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), 28029 Madrid, Spain; (C.A.-P.); (M.M.S.-V.); (V.M.-S.); (M.D.-R.)
- Department of Biomedical Sciences, University of León, 24071 León, Spain
| |
Collapse
|
3
|
Moore JR, Castro Y, Cubbin C, von Sternberg K. Associations of At-Risk Drinking, Current Smoking, and Their Co-Occurrence With Primary Care Service Utilization. Am J Health Promot 2022; 36:429-439. [PMID: 34865517 PMCID: PMC10409595 DOI: 10.1177/08901171211056130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Smoking and at-risk drinking are each associated with lower primary care utilization, but the influence of their co-occurrence is not known. The current study compared associations of endorsement of one behavior vs endorsement of both with primary care utilization. DESIGN Cross-sectional telephone survey. SETTING All United States and Territories. SUBJECTS 246 801 adults aged 18-64. MEASURES The outcome was endorsement of attending a past-year primary care visit. Predictor variables included drinking and smoking status examined individually and combined. ANALYSIS Multivariable logistic regressions, adjusted for socio-demographics and number of chronic health conditions. RESULTS The odds of attending a past-year primary care visit were 24% lower for persons who drank at risk levels compared to the odds of persons who did not drink and 36% lower for persons who smoked vs those who did not smoke. Among persons who endorsed at least one risk behavior, the odds of attending a past-year primary care visit were 25-35% lower for those who engaged in multiple behaviors compared to the odds of persons who engaged in one behavior. CONCLUSION Substance use screening and intervention services in primary care may not be reaching individuals with the greatest need for services. Proactive outreach and identification of primary care utilization barriers are needed, with special consideration of those with co-occurring substance use.
Collapse
Affiliation(s)
- John R. Moore
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| | - Yessenia Castro
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| | - Catherine Cubbin
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| | - Kirk von Sternberg
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| |
Collapse
|
4
|
Bruguera P, Barrio P, Manthey J, Oliveras C, López-Pelayo H, Nuño L, Miquel L, López-Lazcano A, Blithikioti C, Caballeria E, Matrai S, Rehm J, Vieta E, Gual A. Mid and long-term effects of a SBIRT program for at-risk drinkers attending to an emergency department. Follow-up results from a randomized controlled trial. Eur J Emerg Med 2021; 28:373-379. [PMID: 33709997 DOI: 10.1097/mej.0000000000000810] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND IMPORTANCE SBIRT programs (Screening Brief Intervention and Referral to Treatment) for at-risk drinkers in emergency departments (ED) have shown to be effective, particularly at short term. In this article, we report mid and long-term follow-up results of a specialized SBIRT program. A short-term follow-up after 1.5 months showed encouraging results, with more than a 20% greater reduction of at-risk drinking in the intervention group and more than double of successful referrals to specialized treatment. OBJECTIVE We aimed to evaluate the mid and long-term efficacy of an SBIRT program conducted by psychiatrist specialists in addictive disorders and motivational interviewing in the ED of a tertiary hospital. DESIGN, SETTINGS AND PARTICIPANTS We conducted a secondary analysis of a previously published randomized controlled trial of an SBIRT program conducted by alcohol specialists for at-risk drinkers presenting to the ED, measured with the AUDIT-C scale. INTERVENTION OR EXPOSURE Patients were randomized into two groups, with the control group receiving two leaflets: one regarding alcohol use and the other giving information about the study protocol. The intervention group received the same leaflets as well as a brief motivational intervention on alcohol use and, where appropriate, a referral to specialized treatment. OUTCOMES MEASURE AND ANALYSIS Long-term assessment primary outcome was the proportion of at-risk alcohol use measured by AUDIT-C scale. The main effectiveness analysis at 18 weeks and 12 months' follow-up was conducted with multilevel logistic regression analyses. Missing values were imputed with the last observation carried forward. MAIN RESULTS Of 200 patients included in the study, 133 (66.5%) and 131 (65.5%) completed 18 weeks and 1-year follow-up respectively. Although the proportion of risky drinkers was substantially lower in the intervention group (38.5 vs. 57.4% at 4.5 months and 58.5 vs 68.2% at 1 year), these results did not reach statistical significance (OR = 2.15; CI, 0.87-5.33). CONCLUSIONS In this secondary analysis for mid- and long-term effects of a specialized SBIRT program, there was no significant difference in the reduction of risky drinkers at 18 weeks and 1 year. The small size of the studied sample and the low retention rate precluded any significant conclusion, although point estimates suggest a positive effect. Overall, SBIRT programs are an effective tool to reduce alcohol use at short time and to refer patients to specialized treatment; however, its effects seem to decay over time.
Collapse
Affiliation(s)
- Pol Bruguera
- Addictive Behaviors Unit, Clinical Neuroscience Institute, Hospital Clínic
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Pablo Barrio
- Addictive Behaviors Unit, Clinical Neuroscience Institute, Hospital Clínic
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Jakob Manthey
- Center for Clinical Epidemiology and Longitudinal Studies, Institute of Clinical Psychology and Psychotherapy, Dresden University of Technology, Dresden
- Center for Interdisciplinary Addiction Research, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg
- Department of Psychiatry, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Clara Oliveras
- Addictive Behaviors Unit, Clinical Neuroscience Institute, Hospital Clínic
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Hugo López-Pelayo
- Addictive Behaviors Unit, Clinical Neuroscience Institute, Hospital Clínic
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Laura Nuño
- Addictive Behaviors Unit, Clinical Neuroscience Institute, Hospital Clínic
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Laia Miquel
- Addictive Behaviors Unit, Clinical Neuroscience Institute, Hospital Clínic
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Ana López-Lazcano
- Addictive Behaviors Unit, Clinical Neuroscience Institute, Hospital Clínic
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Chrysanthi Blithikioti
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Elsa Caballeria
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Silvia Matrai
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| | - Jürgen Rehm
- Center for Clinical Epidemiology and Longitudinal Studies, Institute of Clinical Psychology and Psychotherapy, Dresden University of Technology, Dresden
- Center for Interdisciplinary Addiction Research, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg
- Institute for Mental Health Policy Research & Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health
- Dalla Lana School of Public Health, Department of Psychiatry, Institute of Medical Science, University of Toronto, Toronto, Canada
- Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Eduard Vieta
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona
- Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
- Centro de Investigación en Red de Salud mental (CIBERSAM), Madrid
| | - Antoni Gual
- Addictive Behaviors Unit, Clinical Neuroscience Institute, Hospital Clínic
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona
- Grup de Recerca en Addiccions Clínic, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain
| |
Collapse
|
5
|
Mejldal A, Andersen K, Behrendt S, Bilberg R, Christensen AI, Lau CJ, Möller S, Nielsen AS. History of healthcare use and disease burden in older adults with different levels of alcohol use. A register-based cohort study. Alcohol Clin Exp Res 2021; 45:1237-1248. [PMID: 33860951 DOI: 10.1111/acer.14615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/12/2021] [Accepted: 04/07/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Only a minority of individuals with problematic alcohol use ever seek alcohol treatment. Knowledge of general help-seeking behavior in the healthcare system can identify possibilities for prevention and intervention. METHOD The current study describes healthcare use, burden of disease, and prior morbidities over a 15-year period by current alcohol use behavior among Danish adults aged 60-70. The Danish National Health Survey 2013 and the baseline assessment of the Elderly Study (2014-2016) were linked to Danish national registers to collect annual information on healthcare use and morbidity for the 15 years prior to inclusion. Participants from the 3 largest Danish municipalities were divided into 4 groups with varying drinking patterns and no recent treatment [12-month abstinent (n = 691), low-risk drinkers (n = 1978), moderate-risk drinkers (n = 602), and high-risk drinkers (n = 467)], and a group of treatment-seeking individuals with a 12-month DSM-5 alcohol use disorder (AUD; n=262). Negative binomial regression models were utilized to compare rates of healthcare use and logistic regressions were used to compare odds of diagnoses. RESULTS Low-, moderate-, and high-risk drinkers had similar rates of past healthcare utilization (low-risk mean yearly number of contacts for primary care 7.50 (yearly range 6.25-8.45), outpatient care 0.80 (0.41-1.32) and inpatient care 0.13 (0.10-0.21)). Higher rates were observed for both the 12-month abstinent group (adjusted RR = 1.16-1.26) and the group with AUD (ARR = 1.40-1.60) compared to the group with low-risk alcohol consumption. Individuals with AUD had higher odds of previous liver disease (adjusted OR = 6.30), ulcer disease (AOR = 2.83), and peripheral vascular disease (AOR 2.71). Twelve-month abstinence was associated with higher odds of diabetes (AOR = 1.97) and ulcer disease (AOR = 2.10). CONCLUSIONS Looking back in time, we found that older adults had regular healthcare contacts, with those who received treatment for AUD having had the highest contact frequency and prevalence of alcohol-related diseases. Thus, healthcare settings are suitable locations for efforts at AUD prevention and intervention.
Collapse
Affiliation(s)
- Anna Mejldal
- Unit of Clinical Alcohol Research, Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Kjeld Andersen
- Unit of Clinical Alcohol Research, Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense C, Denmark.,BRIDGE, Brain Research - Inter-Disciplinary Guided Excellence, University of Southern Denmark, Odense C, Denmark.,Department of Mental Health Odense, Region of Southern Denmark, Vejle, Denmark
| | - Silke Behrendt
- Unit of Clinical Alcohol Research, Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark.,Institute for Psychology, University of Southern Denmark, Odense C, Denmark
| | - Randi Bilberg
- Unit of Clinical Alcohol Research, Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | | | - Cathrine Juel Lau
- Center for Clinical Research and Prevention, Bispebjerg Hospital, København, Denmark.,Frederiksberg Hospital, Frederiksberg, Denmark
| | - Sören Möller
- OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense C, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Anette Søgaard Nielsen
- Unit of Clinical Alcohol Research, Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark.,BRIDGE, Brain Research - Inter-Disciplinary Guided Excellence, University of Southern Denmark, Odense C, Denmark
| |
Collapse
|
6
|
Singh JA. Factors associated with healthcare utilization and mortality in alcohol use disorder hospitalization. Drug Alcohol Depend 2021; 222:108653. [PMID: 33714717 DOI: 10.1016/j.drugalcdep.2021.108653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 02/15/2021] [Accepted: 02/15/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the outcomes of alcohol use disorder (AUD)-hospitalizations. METHODS We used the U.S. National Inpatient Sample (NIS) data from 1998 to 2016 to examine predictors of Healthcare utilization (total hospital charges, discharge destination, length of hospital stay) and in-hospital mortality for AUD-hospitalization outcomes. We used logistic regression to assess the association of patient demographics (age, sex, race/ethnicity, household income), comorbidity (Deyo-Charlson index), insurance payer (Medicare, Medicaid, private, self-pay or other), and hospital characteristics (location/teaching status; hospital bed size; and region) with outcomes RESULTS: There were 5,590,952 primary AUD-hospitalizations from 1998 to 2016; of these 106,419 (1.9 %) died in-hospital. The mean age was 48 years, 73 % were male, 59 % white, and 57 % had a Deyo-Charlson comorbidity score of zero. In multivariable-adjusted analyses of AUD-hospitalizations, older age, female sex, higher Deyo-Charlson index, rural location or hospitals with medium or large bed sizes were associated with significantly higher in-hospital mortality and healthcare utilization. Similarly, South or Western U.S. hospital location, White race, or high income quartile were associated with higher healthcare utilization. Compared to a private insurance payer, Medicare or Medicaid insurance payers were associated with higher healthcare utilization, but lower in-hospital mortality. CONCLUSIONS We identified several independent associations of modifiable and non-modifiable factors with healthcare utilization and mortality outcomes for AUD-hospitalizations. These findings provide an opportunity for prognosis, resource allocation and the development of interventions to improve outcomes of AUD-hospitalizations in the future.
Collapse
Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, 510, 20th Street South, FOT 805B, Birmingham, AL 35233, USA; Department of Medicine at School of Medicine, USA; Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Ave South, Birmingham, AL 35294-0022, USA.
| |
Collapse
|
7
|
Hietanen S, Herajärvi J, Lahtinen S, Käkelä R, Ala-Kokko T, Liisanantti J. Utilization of health care resources, long-term survival and causes of death after intensive care unit admission in relation to high-risk alcohol consumption. JOURNAL OF SUBSTANCE USE 2020. [DOI: 10.1080/14659891.2020.1838636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Siiri Hietanen
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Johanna Herajärvi
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Sanna Lahtinen
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Riikka Käkelä
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Tero Ala-Kokko
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Janne Liisanantti
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| |
Collapse
|
8
|
Lahtinen S, Hietanen S, Herajärvi J, Käkelä R, Ala-Kokko T, Liisanantti J. Use of health care resources in relation to harmful alcohol use prior to intensive care unit admission. JOURNAL OF SUBSTANCE USE 2020. [DOI: 10.1080/14659891.2020.1838634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Sanna Lahtinen
- Department of Anesthesiology, Division of Intensive Care Medicine, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Siiri Hietanen
- Department of Anesthesiology, Division of Intensive Care Medicine, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Johanna Herajärvi
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Riikka Käkelä
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Tero Ala-Kokko
- Department of Anesthesiology, Division of Intensive Care Medicine, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Janne Liisanantti
- Department of Anesthesiology, Division of Intensive Care Medicine, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| |
Collapse
|
9
|
Abstract
Google searches are now a popular way for individuals to seek information about the significance of common symptoms and whether they should seek medical assistance. As analysis of search patterns may help understand the demand for medical care, we examined what times over a 24-hour period and on what days of the week people searched Google for information about common symptoms.
We analysed Google searches for symptoms in the United Kingdom during the week from July 30 to August 5, 2018 using Google Trends. We recorded the time points with the highest search volume for 50 common symptoms relative to other searches, and the day of the week with the highest search peak for each particular symptom.
All of the peak searches for the symptoms we examined occurred during the night between 10pm and 8am. The majority 32/50 (64%) occurred between 3am to 6am with 12/50 (24%) between midnight and 3am. Most symptom searches were more common during the week and lowest during the weekend. Typically, searches for a particular symptom peaked at a similar time each night over the week.
Searches for symptoms are significantly more common during night-time hours, and particularly between 3 and 6am. Symptom searches show relatively stable diurnal and weekly patterns.
Google searches for health information are common and individuals regularly search for their specific symptoms before deciding whether to seek medical care.
Searches for common symptoms are significantly more likely to occur, relative to other searches, during the night-time hours and are highest during the working week and lowest at weekends.
The majority of symptom searches show relatively stable diurnal and weekly patterns.
Google searches for health information are common and individuals regularly search for their specific symptoms before deciding whether to seek medical care.
Searches for common symptoms are significantly more likely to occur, relative to other searches, during the night-time hours and are highest during the working week and lowest at weekends.
The majority of symptom searches show relatively stable diurnal and weekly patterns.
Collapse
|
10
|
Bruguera P, Barrio P, Oliveras C, Braddick F, Gavotti C, Bruguera C, López‐Pelayo H, Miquel L, Segura L, Colom J, Ortega L, Vieta E, Gual A. Effectiveness of a Specialized Brief Intervention for At-risk Drinkers in an Emergency Department: Short-term Results of a Randomized Controlled Trial. Acad Emerg Med 2018; 25:517-525. [PMID: 29418049 DOI: 10.1111/acem.13384] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/19/2018] [Accepted: 02/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have been developed, evaluated, and shown to be effective, particularly in primary care and general practice. Nevertheless, effectiveness of SBIRT in emergency departments (EDs) has not been clearly established. OBJECTIVE We aimed to evaluate the feasibility and efficacy of an SBIRT program conducted by highly specialized professionals in the ED of a tertiary hospital. METHODS We conducted a randomized controlled trial to study the feasibility and efficacy of an SBIRT program conducted by alcohol specialists for at-risk drinkers presenting to the ED, measured with the three-item version of the Alcohol Use Disorder Identification Test (AUDIT-C). Patients were randomized to two groups, with the control group receiving two leaflets-one regarding alcohol use and the other giving information about the study protocol. The intervention group received the same leaflets as well as a brief motivational intervention on alcohol use and, where appropriate, a referral to specialized treatment. The primary outcomes were the proportion of at-risk alcohol use measured by AUDIT-C scale and the proportion of patients attending specialized treatment at 1.5 months. RESULTS Of 3,027 patients presenting to the ED, 2,044 (67%) were potentially eligible to participate, 247 (12%) screened positive for at-risk drinking, and 200 agreed to participate. Seventy-two percent of the participating sample were men, and the mean (±SD) age was 43 (±16.7) years. Follow-up rates were 76.5%. At 1.5 months, the intervention group showed greater reductions in alcohol consumption and fewer patients continuing with at-risk alcohol use (27.8% vs. 48.1%; p = 0.01). The SBIRT program also increased the probability of attending specialized treatment, compared to the control condition (23% vs. 9.8%, p = 0.0119) CONCLUSION: The SBIRT program in the ED was found to be feasible and effective in identifying at-risk drinkers, reducing at-risk alcohol use, and increasing treatment for alcohol problems.
Collapse
Affiliation(s)
- Pol Bruguera
- Addictive Behaviors Unit Clinical Neuroscience Institute, Hospital Clínic Barcelona Spain
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Grup de Recerca en Addiccions Clínic Hospital Clínic de Barcelona IDIBAPS Universitat de Barcelona Red de Trastornos Adictivos (RETICS) Barcelona Spain
- Bipolar Disorder Program Institute of Neuroscience Hospital Clínic University of Barcelona IDIBAPS Barcelona Spain
| | - Pablo Barrio
- Addictive Behaviors Unit Clinical Neuroscience Institute, Hospital Clínic Barcelona Spain
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Grup de Recerca en Addiccions Clínic Hospital Clínic de Barcelona IDIBAPS Universitat de Barcelona Red de Trastornos Adictivos (RETICS) Barcelona Spain
- Bipolar Disorder Program Institute of Neuroscience Hospital Clínic University of Barcelona IDIBAPS Barcelona Spain
| | - Clara Oliveras
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Grup de Recerca en Addiccions Clínic Hospital Clínic de Barcelona IDIBAPS Universitat de Barcelona Red de Trastornos Adictivos (RETICS) Barcelona Spain
| | - Fleur Braddick
- Addictive Behaviors Unit Clinical Neuroscience Institute, Hospital Clínic Barcelona Spain
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Grup de Recerca en Addiccions Clínic Hospital Clínic de Barcelona IDIBAPS Universitat de Barcelona Red de Trastornos Adictivos (RETICS) Barcelona Spain
| | - Carolina Gavotti
- Addictive Behaviors Unit Clinical Neuroscience Institute, Hospital Clínic Barcelona Spain
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Grup de Recerca en Addiccions Clínic Hospital Clínic de Barcelona IDIBAPS Universitat de Barcelona Red de Trastornos Adictivos (RETICS) Barcelona Spain
| | - Carla Bruguera
- Program on Substance Abuse Public Health Agency Government of Catalonia Barcelona Spain
| | - Hugo López‐Pelayo
- Addictive Behaviors Unit Clinical Neuroscience Institute, Hospital Clínic Barcelona Spain
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Grup de Recerca en Addiccions Clínic Hospital Clínic de Barcelona IDIBAPS Universitat de Barcelona Red de Trastornos Adictivos (RETICS) Barcelona Spain
- Bipolar Disorder Program Institute of Neuroscience Hospital Clínic University of Barcelona IDIBAPS Barcelona Spain
| | - Laia Miquel
- Addictive Behaviors Unit Clinical Neuroscience Institute, Hospital Clínic Barcelona Spain
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Grup de Recerca en Addiccions Clínic Hospital Clínic de Barcelona IDIBAPS Universitat de Barcelona Red de Trastornos Adictivos (RETICS) Barcelona Spain
- Bipolar Disorder Program Institute of Neuroscience Hospital Clínic University of Barcelona IDIBAPS Barcelona Spain
| | - Lídia Segura
- Program on Substance Abuse Public Health Agency Government of Catalonia Barcelona Spain
| | - Joan Colom
- Program on Substance Abuse Public Health Agency Government of Catalonia Barcelona Spain
| | - Lluisa Ortega
- Addictive Behaviors Unit Clinical Neuroscience Institute, Hospital Clínic Barcelona Spain
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Grup de Recerca en Addiccions Clínic Hospital Clínic de Barcelona IDIBAPS Universitat de Barcelona Red de Trastornos Adictivos (RETICS) Barcelona Spain
- Bipolar Disorder Program Institute of Neuroscience Hospital Clínic University of Barcelona IDIBAPS Barcelona Spain
| | - Eduard Vieta
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Centro de Investigación en Red de Salud Mental (CIBERSAM) Madrid Spain
- Bipolar Disorder Program Institute of Neuroscience Hospital Clínic University of Barcelona IDIBAPS Barcelona Spain
| | - Antoni Gual
- Addictive Behaviors Unit Clinical Neuroscience Institute, Hospital Clínic Barcelona Spain
- Department of Psychiatry and Clinical Psychobiology University of Barcelona Barcelona Spain
- Grup de Recerca en Addiccions Clínic Hospital Clínic de Barcelona IDIBAPS Universitat de Barcelona Red de Trastornos Adictivos (RETICS) Barcelona Spain
- Bipolar Disorder Program Institute of Neuroscience Hospital Clínic University of Barcelona IDIBAPS Barcelona Spain
| |
Collapse
|
11
|
Davis AK, Walton MA, Bohnert KM, Bourque C, Ilgen MA. Factors associated with alcohol consumption among medical cannabis patients with chronic pain. Addict Behav 2018; 77:166-171. [PMID: 29045928 DOI: 10.1016/j.addbeh.2017.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/06/2017] [Accepted: 10/09/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Chronic pain is the most common reason for medical cannabis certification. Data regarding alcohol use and risky drinking among medical cannabis patients with pain is largely unknown. Therefore, we examined the prevalence and correlates of alcohol use and risky drinking in this population. METHODS Participants completed surveys regarding demographics, pain-related variables, anxiety, cannabis use, and past six-month alcohol consumption. Alcohol use groups were defined using the AUDIT-C [i.e., non-drinkers, low-risk drinkers, and high-risk drinkers (≥4 for men and ≥3 for women)] and compared on demographic characteristics, pain measures, anxiety, and cannabis use. RESULTS Overall, 42% (n=330/780) were non-drinkers, 32% (n=251/780) were low-risk drinkers, and 26% (n=199/780) were high-risk drinkers. Compared to non-drinkers, low- and high-risk drinkers were significantly younger whereas a larger proportion of low-risk drinkers reported being African-American compared to non- or high-risk drinkers. High-risk drinkers reported significantly lower pain severity/interference compared to the other groups; high-risk drinkers were also less likely to be on disability compared to other groups. A multinomial logistic regression showed that patients reporting lower pain severity and less disability had greater odds of being classified a high-risk drinker. CONCLUSIONS High-risk drinking appears common among medical cannabis patients. Future research should examine whether such use is concurrent or consecutive, and the relationship of such co-use patterns to consequences. Nevertheless, individuals treating patients reporting medical cannabis use for pain should consider alcohol consumption, with data needed regarding the efficacy of brief alcohol interventions among medical cannabis patients.
Collapse
Affiliation(s)
- Alan K Davis
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA; University of Michigan Addiction Center, Department of Psychiatry, University of Michigan School of Medicine, 4250 Plymouth Road, Ann Arbor, MI 48109, USA.
| | - Maureen A Walton
- University of Michigan Addiction Center, Department of Psychiatry, University of Michigan School of Medicine, 4250 Plymouth Road, Ann Arbor, MI 48109, USA; University of Michigan Injury Center, University of Michigan School of Medicine, 2800 Plymouth Road, NCRC10-G080, Ann Arbor, MI, 48109, USA
| | - Kipling M Bohnert
- University of Michigan Addiction Center, Department of Psychiatry, University of Michigan School of Medicine, 4250 Plymouth Road, Ann Arbor, MI 48109, USA; HSR&D Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, 2800 Plymouth Road, Building 16, Floor 2, Ann Arbor, MI 48109, USA
| | - Carrie Bourque
- University of Michigan Addiction Center, Department of Psychiatry, University of Michigan School of Medicine, 4250 Plymouth Road, Ann Arbor, MI 48109, USA
| | - Mark A Ilgen
- University of Michigan Addiction Center, Department of Psychiatry, University of Michigan School of Medicine, 4250 Plymouth Road, Ann Arbor, MI 48109, USA; HSR&D Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, 2800 Plymouth Road, Building 16, Floor 2, Ann Arbor, MI 48109, USA
| |
Collapse
|
12
|
Zemore SE, Ye Y, Mulia N, Martinez P, Jones-Webb R, Karriker-Jaffe K. Poor, persecuted, young, and alone: Toward explaining the elevated risk of alcohol problems among Black and Latino men who drink. Drug Alcohol Depend 2016; 163:31-9. [PMID: 27107846 PMCID: PMC4880496 DOI: 10.1016/j.drugalcdep.2016.03.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 03/03/2016] [Accepted: 03/04/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Even given equivalent drinking patterns, Black and Latino men experience substantially more dependence symptoms and other consequences than White men, particularly at low/no heavy drinking. No known studies have identified factors driving these disparities. The current study examines this question. METHODS The 2005 and 2010 National Alcohol Surveys were pooled. Surveys are nationally representative, telephone interviews of the U.S. including Black and Latino oversamples; male drinkers were analyzed (N=4182). Preliminary analyses included negative binomial regressions of dependence symptom and consequence counts testing whether effects for race/ethnicity were diminished when entering potential explanatory factors individually. Additional analyses re-examined effects for race/ethnicity when using propensity score weighting to weight Blacks to Whites, and Latinos to Whites, first on heavy drinking alone, and then on heavy drinking and all explanatory factors supported by preliminary analyses. RESULTS Preliminary regressions suggested roles for lower individual SES, greater prejudice and unfair treatment, and younger age in the elevated risk of alcohol problems among Black and Latino (vs. White) men at low heavy drinking levels; additional support emerged for single (vs. married) status among Blacks and neighborhood disadvantage among Latinos. When Blacks and Latinos were weighted to Whites on the above variables, effects for race/ethnicity on dependence counts were reduced to nonsignificance, while racial/ethnic disparities in consequence counts were attenuated (by >43% overall). CONCLUSIONS Heavy drinking may be especially risky for those who are poor, exposed to prejudice and unfair treatment, young, and unmarried, and these factors may contribute to explaining racial/ethnic disparities in alcohol problems.
Collapse
Affiliation(s)
- Sarah E. Zemore
- Alcohol Research Group, 6475 Christie Ave., Suite 400, Emeryville, CA 94608-1010, United States,Corresponding author. (S.E. Zemore)
| | - Yu Ye
- Alcohol Research Group, 6475 Christie Ave., Suite 400, Emeryville, CA 94608-1010, United States.
| | - Nina Mulia
- Alcohol Research Group, 6475 Christie Ave., Suite 400, Emeryville, CA 94608-1010, United States.
| | - Priscilla Martinez
- Alcohol Research Group, 6475 Christie Ave., Suite 400, Emeryville, CA 94608-1010, United States.
| | - Rhonda Jones-Webb
- University of Minnesota, Division of Epidemiology, School of Public Health, 1300 S. Second Street, Suite 300, Minneapolis, MN 55454-1015, United States.
| | - Katherine Karriker-Jaffe
- Alcohol Research Group, 6475 Christie Ave., Suite 400, Emeryville, CA 94608-1010, United States.
| |
Collapse
|
13
|
MAJORI S, RICCI G, MARCHIORI F, BOCCHI M, ZANNONI M. Prevalence of acute alcohol intoxication in Borgo Trento Hospital Emergency Department (Verona). JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2015; 56:E196-202. [PMID: 26900337 PMCID: PMC4753823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Alcohol is an important factor weighting towards global disease burden, premature death and Disability-Adjusted Life Years. This study examines the burden imposed on the Borgo Trento Verona Hospital Emergency Department (ED) Italy by patients with Acute Alcohol Intoxication (AAI). METHODS A 6-year retrospective study was performed by reviewing medical records in all patients (≥ 16 years old) diagnosed with AAI. Clinical criteria for inclusion in the sample followed those defined in the "Alcohol Intoxication Symptoms" section of DSM-IV-TR. Ambiguous cases presenting traumas potentially related to AAI were confirmed positive using a Blood Alcohol Level (BAL) test before inclusion in the sample. Socio-demographic data, case history, timing of admission/discharge and outcome were collected for each patient. RESULTS One thousand five hundred forty-seven patients (males:females = 6.6:1) were included in the study. With regard to marital status, the crude rate within the sample shows that single and married subjects have a significantly higher prevalence (p < 0.01). When demographic data of residents was taken into consideration, divorced/separated and single categories were significantly more represented (p < 0.05). The admissions appeared fairly constant throughout the week with a higher prevalence of patients aged between 25-55 years, and a significant peak of the youngest age class on weekends. Higher rates of admission were recorded during the late afternoon and night. The triage code of admission appeared uniformly distributed along the week, with the highest prevalence of green code (67.7%), followed by yellow one (25.8%). The analysis of clinical symptoms and BAL highlights that moderate clinical severity concerns almost 50%, and clinically critical severity the 6.6% of cases of access. Admissions rates of foreign patients resulted to be 3 times higher compared to those of natives when adjusted to demographic data. DISCUSSION Social disadvantages such as foreign provenance and social difficulties as unemployment, low money intake, perception of loneliness, and dysfunction in family life were frequently identified in the sample. An exception was found within the youngest age group, where the AAI are mostly related to alcohol abuse during social outings over the weekend. EDs play a crucial role in helping patients with AAI, but prevention of alcohol abuse though implementation of social and sanitary health policies on all ages (but especially among the youngest) is essential.
Collapse
Affiliation(s)
- S. MAJORI
- Department of Public Health and Community Medicine, Hygiene and Environmental Occupational Preventive Medicine Division, University of Verona, Italy;,Correspondence: Silvia Majori, Department of Public Health and Community Medicine, Hygiene and Environmental Occupational Preventive Medicine Division, University of Verona, Istituti Biologici II, strada Le Grazie 8, 37134 Verona, Italy - Tel. +39 045 8027653 - E-mail:
| | - G. RICCI
- Accident and Emergency Department of "Borgo Trento" Hospital, Azienda Ospedaliera Universitaria Integrata Verona, Italy
| | - F. MARCHIORI
- Specialisation School in Hygiene and Preventive Medicine, University of Verona, Italy
| | - M. BOCCHI
- Specialisation School in Hygiene and Preventive Medicine, University of Verona, Italy
| | - M. ZANNONI
- Accident and Emergency Department of "Borgo Trento" Hospital, Azienda Ospedaliera Universitaria Integrata Verona, Italy
| |
Collapse
|