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Methods: This was a retrospective cohort analysis of consecutive patients diagnosed with toxicity related to cannabis use. Patients were seen at seven emergency departments (EDs) over a 24-month study period (November 2018-October 2020). Spanning 13 counties in Michigan, affiliated institutions included three rural medical centers, three university-affiliated hospitals, and a children's tertiary care facility. Data collected included demographics, clinical features, and treatment outcomes in patients presenting to the ED with neuropsychiatric symptoms (NPS) versus those experiencing other forms of cannabis toxicity. Chisquared and t-tests were used to compare these two groups across key demographic and outcome variables. One investigator performed a blinded critical review of a random sample of 10% of the charts to determine inter-rater reliability using kappa statistics.Results: During the study period, 1214 patients were evaluated for cannabis toxicity. A total of 584 patients (48.1%) had a neuropsychiatric chief complaint (NPS group) and 630 (51.9%) experienced other forms of cannabis toxicity, predominantly symptoms of intoxication (51.0%) or cannabis hyperemesis syndrome (37.5%). The NPS group presented with acute anxiety (37.5%), suicidal ideation (18.4%), depression (16.1%), hallucinations (9.5%), mania (5.9%), seizures (5.5%), psychosis (4.6%), and paranoia (4.5%). NPS patients were more likely to younger (25.3 vs 29.2 years, P<0.001), have comorbidities (15.3 vs 9.2%, P¼0.001) and a history of polysubstance abuse (13.2 vs 8.6%, P¼0.004). These patients also had a longer ED length-of-stay (7.3 vs 4.0 hours, P<0.001) and significantly more hospital admissions (41.9% vs 6.4%, P<0.001). Reliability of data collection (k ¼ 0.91) showed excellent agreement.Conclusions: Neuropsychiatric toxicity is common after acute or chronic cannabis exposures, occurring in nearly half of ED patients in this community-based study. These troublesome findings highlight the risks associated with the use of cannabis for recreational or therapeutic purposes.

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Background: Transgender, transsexual, gender variant, and intersex people (TGI) have decreased access to care and poorer health outcomes compared to their LGB counterparts. Little has been studied and documented about TGI patient emergency department (ED) care experiences and barriers to care. Study Objectives: Identify major themes related to TGI patient access and utilization of emergency services and develop preliminary hypotheses about TGI patient emergency care experiences, systemic barriers to TGI access to emergency care, and potential provider-level knowledge deficits. Methods: Four focus groups were conducted in 2014 with TGI Rhode Islanders (RI) over the age of 18 years of age who had been a patient in an ED in the last 5 years. Participants were recruited from the community by email listserve announcements, outreach to local TGI organizations, and periodical advertisements. The study team developed an interview guide to elicit ED experiences and barriers to care that was reviewed by a qualitative research advisory committee. Deidentified participant demographic information was collected using a standardized instrument. All discussions were captured on digital audio recorders and professionally transcribed. The study team developed a coding guide with codes grouped into major themes and subthemes, and a final thematic framework developed collaboratively. Focus group transcripts were reviewed and coded by two independent investigators; discrepancies were resolved through discussion. Results: Among 32 participants, 43% were female-to-male or male-identified, 75% were white. Over 40% noted prior avoidance of the ED, with fear of discrimination noted as the most significant barrier. Major discussion themes on ED experiences included lack of privacy, poor provider competency and communication, and common experiences of grossly inappropriate, awkward and/or inconsiderate reactions of health care providers to revelations of gender identity. Overall, participants preferred direct communication from providers regarding their gender identity and specific health needs, but cautioned against reducing all health concerns to gender identity. Recommendations for improvement focused on provider deficits, need for provider training and education, and infrastructure changes to maintain privacy. Conclusion: Efforts to improve TGI ED experiences should focus on provider competency, communication training, and ED infrastructure changes to address safety and privacy concerns. Further research with increased inclusion of transwomen and people of color is needed to identify themes that may not have been raised in this preliminary investigation.