"Practicing" medicine without risk: students' and educators' responses to high-fidelity patient simulation

PURPOSE

To understand the responses of medical students and educators to high-fidelity patient simulation, a new technology allowing "practice without risk."

METHOD

Pilot groups of students (n = 27) and educators (n = 33) were exposed to a simulator session, then surveyed with multiple-choice and open-ended questions. Open-ended comments were transcribed and coded. They were analyzed for recurring themes and tested for inter-rater agreement. An independent focus group subsequently performed higher-level thematic analysis.

RESULTS

Overall, 85% of the students rated the session excellent and 85% of the educators rated it excellent or very good. Over 80% of both groups thought that simulator-based training should be required for all medical students. Analytic categories derived from written comments were: Overall Assessment (i.e., "generally good experience"); Process Descriptors (i.e., "very realistic"); Teaching Utility (i.e., "broad educational tool"); Pedagogic Efficacy (i.e., "promotes critical thinking"); and Goals for Future Use (i.e., "more practice sessions"). Thirty percent of students and 38% of educators were impressed by the realism of the simulator, and they (37% and 25%, respectively) identified the ability to "practice" medicine as the primary advantage of simulation. The focus group rated cost as the major current disadvantage (66%).

CONCLUSIONS

Students' and educators' responses to high-fidelity patient simulation were very positive. The ability to practice without risk must be weighed against the cost of this new technology.

Small-Carrion penile prosthesis. New implant for management of impotence

The etiology of impotence and a review of various techniques in treatment are discussed. A perineal surgical approach with a new type of paired sponge-filled silicone prostheses is described. The prostheses are inserted into previously dilated corpora cavernosa. Of the initial 31 patients, excellent results were obtained 27, and a good result in 1. Of the 3 patients with initial serious complications, adequate functional results were attained in 2. The distinct advantages and potential complications using the Small-Carrion penile prosthesis and surgical technique are discussed.

Preventive care in the emergency department, Part I: Clinical preventive services--are they relevant to emergency medicine? Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group

In 1998 the Society for Academic Emergency Medicine's (SAEM's) Board of Directors asked the SAEM Public Health and Education Task Force to develop recommendations for prevention, screening, and counseling activities to be conducted in emergency departments (EDs). The Task Force's work was divided into two phases: 1) a discussion of the rationale for preventive services in the ED, along with generation of a preliminary list of prevention activities that could be studied for ED implementation; and 2) a formal evidence-based review of topics chosen from the preliminary list, along with recommendations for ED implementation and further study. This paper represents Phase I of the project. Phase II, the formal evidence-based review and recommendations, is published separately in this issue.

Protective effect of intrarenal calcium membrane blockers before or after renal ischemia. Functional, morphological, and mitochondrial studies

The present study examined whether a pre- or postischemic infusion of verapamil (V) or a postischemic infusion of nifedipine (N), drugs which block calcium (Ca++) influx across plasma membranes, provides protection against ischemic acute renal failure (ARF) in dogs. Renal hemodynamics and excretory function were examined 1 h (initiation phase) and 24 h (maintenance phase) after a 40-min intrarenal infusion of norepinephrine (NE). In each case, the uninfused contralateral kidney served as control. Four groups were studied: (a) dogs receiving NE alone; (b) dogs receiving an intrarenal infusion of V for 30 min before NE (V + NE); (c) dogs in which intrarenal V was infused for 2 h, beginning immediately after completion of NE infusion (NE + V); and (d) dogs in which intrarenal N was infused for 2 h, beginning immediately after completion of NE infusion (NE + N). Glomerular filtration rate (GFR) in the NE kidneys, as assessed by inulin clearance, at 1 and 24 h averaged 2.4 +/- 1.1 and 5.0 +/- 2.0 ml/min, respectively, as compared with control kidney GFRs of 28.0 +/- 3.5 and 43.8 +/- 5.0 ml/min, respectively (both at least P less than 0.01). In the V + NE group, GFR at 1 and 24 h averaged 15.0 +/- 5.5 and 31.0 +/- 4.5 ml/min, respectively, both at least P less than 0.05 as compared with values from NE kidneys. GFRs in the NE + V group averaged 15.0 +/- 2.4 and 16.3 +/- 3.6 ml/min at 1 and 24 h, both at least P less than 0.02 as compared with values from NE kidneys. GFR in the NE + N group averaged 18.6 +/- 6.0 ml/min at 24 h (P less than 0.05 as compared with GFRs in the NE kidneys). In addition, function of cortical mitochondria (Mito) was examined at the end of the 40-min NE infusion and after 1 and 24 h of reperfusion in the NE alone and NE + V groups. Mito respiration, assessed by acceptor control ratios, was reduced at each period in the NE alone kidneys. After 24 h, these Mito had accumulated Ca++ and exhibited reduced Ca++ uptake and increased Ca++ release rates. Mito from NE + V kidneys respired normally, did not accumulate Ca++, and exhibited no alterations in Ca++ uptake or release. Light and electron microscopy also demonstrated morphological protection of V against tubular necrosis and cell injury. Mito from the NE + N kidneys also respired normally and did not accumulate significant amounts of Ca++. The results of the present studies therefore demonstrated that chemically dissimilar calcium entry blockers exert substantial functional, cellular, and morphological protection against experimental ischemic ARF. These findings are compatible with the hypothesis that increased cytosolic Ca++ is critically important in the maintenance of renal vasoconstriction and the development of cellular necrosis with subsequent tubular obstruction in NE-induced ischemic ARF. V or N may provide protection against renal injury by retarding any increase in cytosolic Ca++ in renal vasculature and epithelium.

5-HETE: uptake, distribution, and metabolism in MDCK cells

The interaction of (S)-5-hydroxy-6-trans-8,11,14-cis-eicosatetraenoic acid (5-HETE) with Madin-Darby canine kidney (MDCK) cells was investigated to determine whether this lipoxygenase product might influence tubular epithelial function. When incubated with arachidonic acid, MDCK cells failed to synthesize any 5-HETE. However, MDCK cells can take up 5-HETE to a much greater extent than either 12- or 15-HETE. 5-HETE uptake occurred from both the apical and basolateral surfaces and was not saturated at concentrations up to 10 microM. Much of the 5-HETE was incorporated into phospholipids, primarily phosphatidylcholine and phosphatidylethanolamine. After a 1-h incubation 5-HETE was found to be localized in either the microsomal and/or plasma membrane of MDCK cells. After pulse labeling for 1 h, MDCK cells released 35% of 5-HETE compared with 10% of the incorporated arachidonate during the next 24 h, indicating a much more rapid turnover of newly incorporated 5-HETE. When MDCK cells were incubated with 5.0 microM 5-HETE, their capacity to produce prostaglandin E2 was reduced greater than 50% in as little as 5.0 min. Since 5-HETE enters epithelial phospholipids and reduces prostaglandin production, it apparently has the capacity to modulate renal function if it is released in the proximity of the tubular epithelium during inflammatory reactions.

Auditory delayed matching in the bottlenose dolphin

A bottlenose dolphin, already highly proficient in two-choice auditory discriminations, was trained over a nine-day period on auditory delayed matching-to-sample and then tested on 346 unique matching problems, as a function of the delay between the sample and test sounds. Each problem used new sounds and was from five to 10 trials long, with the same sound used as the sample for all trials of a problem. At each trial, the sample was projected underwater for 2.5 sec, followed by a delay and then by a sequence of two 2.5-sec duration test sounds. One of the test sounds matched the sample and was randomly first or second in the sequence, and randomly appeared at either a left or right speaker. Responses to the locus of the matching test sound were reinforced. Over nine, varying-sized blocks of problems, the longest delay of a set of delays in a block was progressively increased from 15 sec initially to a final value of 120 sec. There was a progressive increase across the early blocks in the percentage of correct Trial 1 responses. A ceiling-level of 100% correct responses was then attained over the final six blocks, during which there were 169 successive Trial 1 responses bracketed by two Trial 1 errors (at 24- and 120-sec delays). Performance on trials beyond the first followed a similar trend. Finally, when the sample duration was decreased to 0.2 sec or less, matching performance on Trial 1 of new problems dropped to chance levels.

Deficient plasticity in the primary visual cortex of alpha-calcium/calmodulin-dependent protein kinase II mutant mice

The recent characterization of plasticity in the mouse visual cortex permits the use of mutant mice to investigate the cellular mechanisms underlying activity-dependent development. As calcium-dependent signaling pathways have been implicated in neuronal plasticity, we examined visual cortical plasticity in mice lacking the alpha-isoform of calcium/calmodulin-dependent protein kinase II (alpha CaMKII). In wild-type mice, brief occlusion of vision in one eye during a critical period reduces responses in the visual cortex. In half of the alpha CaMKII-deficient mice, visual cortical responses developed normally, but visual cortical plasticity was greatly diminished. After intensive training, spatial learning in the Morris water maze was severely impaired in a similar fraction of mutant animals. These data indicate that loss of alpha CaMKII results in a severe but variable defect in neuronal plasticity.

The hospital emergency department as a social welfare institution

In an era of social welfare reform marked by the erosion of a societal safety net, few institutions remain that can guarantee assistance to those most in need. The hospital emergency department is perhaps the only local institution where professional help is mandated by law, with guaranteed availability for all persons, all the time, regardless of the problem. Although the ED serves as a true social safety net, its potential as a social welfare institution generally goes underestimated, hampering its full development as an effective societal resource. More of the disadvantaged may pass through the ED than through any other community institution, making it a logical site not only for the treatment of acute illness, but also for the identification of basic social needs and the extension of existing community resources. By helping more fully incorporate the ED into the total care of its community, emergency physicians can become leaders in the design and implementation of integrated sociomedical systems of care.

Safety net research in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on "The Unraveling Safety Net"

A primary goal of the Academic Emergency Medicine Consensus Conference, "The Unraveling Safety Net: Research Opportunities and Priorities," was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.

Initial emergency department diagnosis and return visits: risk versus perception

STUDY OBJECTIVES

To identify diagnostic predictors of return emergency department visits, and to compare actual and perceived associations between initial ED diagnosis and revisits to help identify target diagnoses for prevention strategies.

METHODS

This 2-part study involved a retrospective observational study and a health professional survey. The study population consisted of all patients with 2 or more visits to the University of Michigan ED within a 3-day period between July 1995 and June 1996 ("early-return visitors"). Billing records identified the initial diagnoses of subsequent return visitors. The prevalence of each initial diagnosis was determined in the general ED population (n=52,553), early-return population (n=1,422), and early-return population admitted to the hospital ("return-admit," n=313). Surveys were distributed to all ED health professionals to assess their perception of the diagnoses most likely to return within 3 days. Relative risk (RR) ratios and 95% confidence intervals (CIs) were calculated.

RESULTS

Dehydration was the most common diagnosis in the general, early-return, and return-admit populations (prevalence: 7%, 15%, 25%, respectively). Dehydration was also the diagnosis with the highest risk for both early return and subsequent admission on early return (RR [95% CI]: 2.3 [2.0-2.6], 1.8 [1.5-2.3], respectively). Nearly two thirds of health professionals, however, did not identify dehydration as a diagnosis at high risk for return, and almost half did not consider dehydration a high risk for admission.

CONCLUSION

Initial ED diagnosis may be a useful predictor of early ED return and admission. Patients with an initial diagnosis of dehydration are at particularly high risk for early return and admission, yet providers underestimate the risk in this very common group. Screening a return ED population for high-frequency diagnoses may reveal underrecognized target groups for specific prevention strategies.

Human progesterone receptor transformation and nuclear down-regulation are independent of phosphorylation

We have studied the phosphorylation of progesterone receptors (PR) in T47Dco human breast cancer cells using a monoclonal antibody directed against human PR called AB-52. This antibody recognizes both the A- (Mr approximately 94,000) and B- (Mr approximately 120,000) hormone binding proteins of PR, and was used to immunoprecipitate phosphorylated receptors isolated from cells incubated in vivo with [32P]orthophosphate. The specific activity, or phosphorylation levels, relative to protein levels was quantified by combined immunoblotting and autoradiography followed by densitometry. We find that immunopurified untransformed hormone-free receptors, which have a characteristic triplet B, singlet A structure, are phosphoproteins with similar levels of phosphate incorporation in all protein bands. If PR are first transformed to the nuclear binding form by treatment of cells with progesterone, and then labeled with [32P]orthophosphate, the receptor proteins are additionally phosphorylated. These chromatin-bound hormone occupied receptors incorporate five to 10 times more labeled phosphate per total receptor protein than do PR from untreated cells during the same [32P]incubation time. The second round of phosphorylation may also account for mobility shifts of transformed A- and B-receptors observed in sodium dodecyl sulfate-polyacrylamide gels. Both untransformed and transformed species of A- and B-receptors are phosphorylated only on serine residues, and neither the extent of phosphorylation, nor the phosphoamino acids, are affected by treatment of the cells with epidermal growth factor or insulin. We previously reported that after hormone binding and transformation of receptors to the tight chromatin binding state, PR undergo processing, or nuclear down-regulation. AB-52 was used to compare PR protein and phosphorylation levels when cells were treated for 0.5-48 h with progesterone or the synthetic progestin R5020. Both agonists lead to hyperphosphorylation of nuclear PR before phosphorylation levels decrease, in parallel with the drop in protein levels as receptors down-regulate. Treatment of cells with RU 486, an antiprogestin, leads to PR transformation as determined by immunoblotting, but subsequent down-regulation does not occur. After transformation, chromatin-bound RU 486-occupied receptors become intensely phosphorylated however, with specific activities 15 times greater than those of untransformed PR. Since these receptors are phosphorylated but not processed, the hormone-induced nuclear phosphorylation of PR is unlikely to be a signal for receptor processing.(ABSTRACT TRUNCATED AT 400 WORDS)

Nonsurgical treatment and early return to activity leads to improved Achilles tendon fatigue mechanics and functional outcomes during early healing in an animal model

Achilles tendon ruptures are common and devastating injuries; however, an optimized treatment and rehabilitation protocol has yet to be defined. Therefore, the objective of this study was to investigate the effects of surgical repair and return to activity on joint function and Achilles tendon properties after 3 weeks of healing. Sprague-Dawley rats (N = 100) received unilateral blunt transection of their Achilles tendon. Animals were then randomized into repaired or non-repaired treatments, and further randomized into groups that returned to activity after 1 week (RTA1) or after 3 weeks (RTA3) of limb casting in plantarflexion. Limb function, passive joint mechanics, and tendon properties (mechanical, organizational using high frequency ultrasound, histological, and compositional) were evaluated. Results showed that both treatment and return to activity collectively affected limb function, passive joint mechanics, and tendon properties. Functionally, RTA1 animals had increased dorsiflexion ROM and weight bearing of the injured limb compared to RTA3 animals 3-weeks post-injury. Such functional improvements in RTA1 tendons were evidenced in their mechanical fatigue properties and increased cross sectional area compared to RTA3 tendons. When RTA1 was coupled with nonsurgical treatment, superior fatigue properties were achieved compared to repaired tendons. No differences in cell shape, cellularity, GAG, collagen type I, or TGF-β staining were identified between groups, but collagen type III was elevated in RTA3 repaired tendons. The larger tissue area and increased fatigue resistance created in RTA1 tendons may prove critical for optimized outcomes in early Achilles tendon healing following complete rupture. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2172-2180, 2016.

Hydroxyeicosatetraenoic acid metabolism in cultured human skin fibroblasts. Evidence for peroxisomal beta-oxidation

To determine whether the peroxisome is responsible for hydroxyeicosatetraenoic acid (HETE) oxidation, 12- and 15-HETE oxidation was measured in normal and peroxisomal deficient skin fibroblasts from patients with Zellweger's (cerebrohepatorenal) syndrome. When incubated for 1 h with normal fibroblasts, reverse phase HPLC indicated that 24% of the 12-HETE radioactivity was converted to one major polar metabolite. Chemical derivatization followed by reverse phase HPLC and TLC indicated that this metabolite is 8-hydroxyhexadecatrienoic acid [16:3(8-OH)]. Similarly, 33% of the added 15-HETE was also converted to a more polar metabolite. Neither 12- nor 15-HETE were converted to any metabolites by the peroxisomal deficient (Zellweger) cells. No defect in HETE oxidation was found in other human fibroblast cell lines with diverse metabolic abnormalities. Zellweger fibroblasts accumulated increased amounts of 12-HETE, compared with normal fibroblasts. As in the normal cells, most of the 12-HETE incorporated into Zellweger fibroblasts was present in the choline and ethanolamine phosphoglycerides. Protein synthesis, lysosomal acid lipase activity, and mitochondrial butyrate oxidation were not impaired in the Zellweger fibroblasts. Since the Zellweger cells do not convert 12- and 15-HETE to oxidative metabolites, peroxisomes appear to be the cellular organelle responsible for HETE oxidation.

The impact of immunosuppressive regimens on the cost of liver transplantation--results from the U.S. FK506 multicenter trial

In an effort to determine the total one-year cost of liver transplantation, the underlying drivers of that cost, and any cost differences between alternative immunosuppressive regimens, an analysis was performed comparing the average one-year posttransplant charges of 322 patients participating in the "U.S. Multi-center Prospective Randomized Trial Comparing FK-506 to Cyclosporine in Liver Transplantation." Total one-year inpatient charges including all readmissions were examined. Professional fees and outpatient charges were excluded. Costs for tacrolimus drug and blood assays were assumed to be equal to those in the CsA group. For patients completing the study, the tacrolimus group had an average length of stay and average one-year cost seven days (P = .06) and $19,290 (P = .05) lower than the CsA group. The difference in rejection profiles between the two arms seems to largely account for the lower costs. The tacrolimus arm consistently had fewer patients in the more severe rejection groups. Increased incidence and severity of rejection were directly related to higher average lengths of stay and costs of transplantation (P < .001). Tacrolimus immunosuppression during the first year after liver transplantation is more cost-effective than CsA in achieving similar patient and graft survival rates. Differing incidence and severity of rejection can dramatically affect the first-year cost of liver transplantation.

Slowed nerve conduction with wrist flexion in carpal tunnel syndrome

Phalen's wrist flexion test may reproduce the sensory symptoms of carpal tunnel syndrome (CTS). We have used this test in conjunction with motor and sensory latency studies in 20 patients with symptomatic CTS in one or both hands. The test caused an increase in the motor or sensory latency in half the patients. In 2 patients the latencies were abnormal only after wrist flexion. The test may thus be useful in diagnosis of borderline cases.

Treatment resistant depression and axis I co-morbidity

BACKGROUND

Treatment resistant depression (TRD) continues to present a formidable challenge to clinicians, accounts for over half of the annual costs associated with treatment for depression and causes great frustration to patients. Although there have been studies attempting to define TRD, little information is available as to the cause of TRD. One suggestion is that patients with TRD have a greater frequency of co-morbid psychiatric disorders, which explains their resistance to standard antidepressant treatments. The objective of this study was to compare the co-morbidity of Axis I disorders between a sample of TRD patients and a sample of non-TRD patients.

METHODS

TRD and non-TRD patients, recruited from two separate antidepressant treatment studies, were assessed for Axis I co-morbidity using the SCID-P for the DSM-III-R. Patients for the two samples were then matched for baseline HAM-D-17 total score and gender.

RESULTS

Results reveal that non-TRD patients had a higher rate of both lifetime and current generalized anxiety disorder co-morbidity than did the TRD patients. No other statistically significant differences in Axis I co-morbidity were found.

CONCLUSIONS

These findings do not support the idea that current or lifetime Axis I co-morbidity is more common in TRD than non-TRD patients. In fact, the only statistical difference showed non-TRD patients with higher co-morbidity rates.

Effects of 12-HETE on renal tubular epithelial cells

The interaction of 12-HETE with MDCK cells was investigated to determine whether this lipoxygenase product might influence tubular epithelial function. MDCK cells took up 12-HETE from both the luminal and interstitial surfaces. Much of the 12-HETE was incorporated into phospholipids but, unlike arachidonic acid, there was no specificity for the sn-2 position. 12-HETE was incorporated without chemical modification, suggesting that it might perturb tight packing in the lipid bilayer. 12-HETE uptake was reduced by the presence of arachidonic acid, but not by oleic acid. 12-HETE was removed from the cell lipids more rapidly than arachidonic acid and it was released into the medium in the form of both more and less polar metabolites. When MDCK cells were incubated with 12-HETE, their capacity to produce prostaglandin E2 was reduced. Since 12-HETE enters epithelial phospholipids and is converted to metabolic products and reduces prostaglandin production, it apparently has the capacity to modulate renal function if it is released in the proximity of the tubular epithelium.

Transformation-sensitive isoactin in passaged chick embryo fibroblasts transformed by Rous sarcoma virus

Transformation by Rous sarcoma virus (RSV) has been reported to block the expression of differentiated cell products in chicken cells. The expression of these proteins may or may not be suppressed when temperature-sensitive mutants are shifted from the nonpermissive to the permissive temperature. A general characteristic of cellular transformation is the disruption of the microfilament system. In passaged chick embryo fibroblast cultures (CEF), this system is principally composed of isomeric forms of actin designated alpha, beta, and gamma by their isoelectric focusing and when subjected to SDS-PAGE behavior. We present evidence that an alpha-actin in CEF cultures, identified by its electrofocusing behavior, retention in the cytoskeleton, and DNase 1 binding properties, is selectively and dramatically reduced in amount upon transformation by RSV. Little or no reduction is observed in the beta- and gamma-isoactins. The reduction of alpha-actin is shown to be reversible and transformation related by use of a temperature-sensitive mutant, tsNY68. The decrease in this transformation-sensitive isoactin is apparently due to a decrease in synthesis, though other possibilities are discussed. A specific decrease in a particular isoactin after transformation may give insight into the mechanism by which the microfilaments are normally maintained.

Coinfection with Campylobacter species: an epidemiological problem?

AIMS

To determine the frequency of coinfection with multiple strains in sporadic cases of human Campylobacter infection.

METHOD AND RESULTS

During 1999 10 single colonies of Campylobacter were cultured from each of 53 positive faecal samples. Five isolates were taken from nonselective agar after passive filtration of faecal suspensions and five isolates were taken from selective agar plates. All isolates were sero- and phage typed and their antibiotic resistance determined. Pulsed-field gel electrophoresis and flagellin gene typing were performed on selected isolates. One patient was infected with Camp. coli, the remainder with strains of Camp. jejuni. The majority of patients was infected with a single strain of Campylobacter, but from each of four samples, 7.5%, two strains of Camp. jejuni, confirmed by molecular typing, were identified.

CONCLUSION

Coinfection occurs in sporadic cases of campylobacteriosis.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study has implications in outbreak investigation when distinct strains have been isolated from epidemiologically related patients and/or the suspected source or vehicle.

Renal concentration defect following nonoliguric acute renal failure in the rat

The mechanism of impaired renal concentrating ability following nonoliguric ischemic acute renal failure was studied in the rat. Fifty min of complete occlusion of the renal artery and vein with contralateral nephrectomy resulted in reversible, nonoliguric acute renal failure. Eight days following induction of acute renal failure, a defect in 30 hr dehydration urine osmolality was present when experimental animals were compared with uninephrectomized controls (1,425 +/- 166 versus 2,267 +/- 127 mOsm/kg water respectively, P less than 0.001). Comparable postdehydration plasma vasopressin levels in experimental and control animals and an impaired hydro-osmotic response to exogenous vasopressin in experimental animals documented a nephrogenic origin of the defect in urine concentration. Lower urinary excretion of prostaglandin E2 in experimental animals and a failure of cyclo-oxygenase inhibition with 10 mg/kg of indomethacin to improve dehydration urine osmolality suggested that prostaglandin E2 antagonism of vasopressin action did not contribute to the concentration defect. Postdehydration inner medullary (papillary) interstitial tonicity was significantly reduced in experimental animals versus controls (870 +/- 85 versus 1,499 +/- 87 mOsm/kg water respectively, P less than 0.001). To determine if this decreased interstitial tonicity was due to vascular mechanisms, papillary plasma flow was measured and found to be equivalent in experimental and control animals. To examine a role for biochemical factors in the renal concentration defect, cyclic nucleotide levels were measured in cytosol and membrane fragments. A decrease in vasopressin and sodium fluoride-stimulated adenylate cyclase was found in outer medullary tissue of experimental animals. In contrast, vasopressin-stimulated adenylate cyclase activity was comparable in the inner medullary tissue of control and experimental animals. Our study suggests a defect in generation of renal inner medullary interstitial solute as a mechanism of the impaired urinary concentration observed in this model of acute renal failure.

Where health and welfare meet: social deprivation among patients in the emergency department

CONTEXT

As a safety net provider for many disadvantaged Americans, the emergency department (ED) may be an efficient site not only for providing acute medical care, but also for addressing serious social needs.

OBJECTIVE

To characterize the social needs of ED patients, and to evaluate whether the most disadvantaged patients have connections with the health and welfare system outside the ED.

DESIGN

Cross-sectional survey conducted over 24 hours in the fall of 1997.

SETTING

Three EDs: an urban public teaching hospital, a suburban university hospital, and a semirural community hospital.

PARTICIPANTS

Consecutive patients presenting for care, including those transported by ambulance. The survey response rate was 91% (N = 300; urban = 115, suburban = 102, rural = 83).

MAIN OUTCOME MEASURE

Index of socioeconomic deprivation described by the US Census Bureau (based on food, housing, and utilities).

RESULTS

Of all ED patients, 31% reported one or more serious social deprivations. For example, 13% of urban patients reported not having enough food to eat, and 9% of rural patients reported disconnection of their gas or electricity (US population averages both less than 3%). While 40% of all patients had no consistent health care outside the ED (< or = 1 visit/year), those with higher levels of social deprivation had the least contact with the health care system outside the ED (P < .01). Although those with higher levels of deprivation were more likely to receive public assistance, still almost one-quarter of patients with high-level social deprivation were not receiving public aid.

CONCLUSION

Many ED patients suffer from fundamental social deprivations that threaten basic health. The most disadvantaged of these patients frequently lack contact with other medical care sites or public assistance networks. Community efforts to address serious social deprivation should include partnerships with the local ED.