Does the implementation of a trauma system affect injury-related morbidity and economic outcomes? A systematic review

BACKGROUND

Trauma accounts for a huge burden of disease worldwide. Trauma systems have been implemented in multiple countries across the globe, aiming to link and optimise multiple aspects of the trauma care pathway, and while they have been shown to reduce overall mortality, much less is known about their cost-effectiveness and impact on morbidity.

METHODS

We performed a systematic review to explore the impact the implementation of a trauma system has on morbidity, quality of life and economic outcomes, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All comparator study types published since 2000 were included, both retrospective and prospective in nature, and no limits were placed on language. Data were reported as a narrative review.

RESULTS

Seven articles were identified that met the inclusion criteria, all of which reported a pre-trauma and post-trauma system implementation comparison in high-income settings. The overall study quality was poor, with all studies demonstrating a severe risk of bias. Five studies reported across multiple types of trauma patients, the majority describing a positive impact across a variety of morbidity and health economic outcomes following trauma system implementation. Two studies focused specifically on traumatic brain injury and did not demonstrate any impact on morbidity outcomes.

DISCUSSION

There is currently limited and poor quality evidence that assesses the impact that trauma systems have on morbidity, quality of life and economic outcomes. While trauma systems have a fundamental role to play in high-quality trauma care, morbidity and disability data can have large economic and cultural consequences, even if mortality rates have improved. The sociocultural and political context of the surrounding healthcare infrastructure must be better understood before implementing any trauma system, particularly in resource-poor and fragile settings.

PROSPERO REGISTRATION NUMBER

CRD42022348529 LEVEL OF EVIDENCE: Level III.

Adult Congenital Heart Disease in the Emergency Department

While congenital heart disease historically was a pathology primarily restricted to specialized pediatric centers, advances in technology have dramatically increased the number of people living into adulthood, the number of complications faced by these patients, and the number of patients visiting non-specialized emergency departments for these concerns. Clinicians need to be aware of the issues specific to patients' individual congenital defects but also have an understanding of how typical cardiac pathology may manifest in this special group of patients. This manuscript attempts to provide an overview of this diverse but increasingly common group of adult patients with congenital heart diseases, including a review of their anatomical variants, the complications they face at the highest rates, and ways that emergency physicians may need to manage these patients differently to avoid causing harm.

Emergency department utilization among patients who receive outpatient specialty care for headache: A retrospective cohort study analysis

OBJECTIVES

To compare clinical characteristics among outpatient headache clinic patients who do and do not self-report visiting the emergency department for headache.

BACKGROUND

Headache is the fourth most common reason for emergency department visits, compromising 1%-3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self-report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization.

METHODS

This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self-reported questionnaires. Associations between self-reported emergency department utilization and demographics, clinical characteristics, and patient-reported outcome measures (PROMs: Headache Impact Test [HIT-6], headache days per month, current headache/face pain, Patient Health Questionnaire-9 [PHQ-9], Patient-Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated.

RESULTS

Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self-reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78-0.85] per decade), Black patients (vs. White patients) (1.47 [1.26-1.71]), Medicaid (vs. private insurance) (1.50 [1.29-1.74]), and worse area deprivation index (1.04 [1.02-1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT-6 (1.35 [1.30-1.41] per 5-point increase), higher (worse) PHQ-9 (1.14 [1.09-1.20] per 5-point increase), and lower (worse) PROMIS-GH Physical Health T-scores (0.93 [0.88-0.97]) per 5-point increase.

CONCLUSION

Our study identified several characteristics associated with self-reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department.

The Impact of Trauma System Implementation on Patient Quality of Life and Economic Burden: A Systematic Review Study Protocol

Background

Trauma accounts for 10% of global mortality, with increasing rates disproportionally affecting low- and middle-income countries. In an attempt to improve clinical outcomes after injury, trauma systems have been implemented in multiple countries over recent years. However, whilst many studies have subsequently demonstrated improvements in overall mortality outcomes, less is known about the impact trauma systems have on morbidity, quality of life, and economic burden. This systematic review seeks to assess the existing evidence base for trauma systems with these outcome measures.

Methods

This review will include any study that assesses the impact implementation of a trauma system has on patient morbidity, quality of life, or economic burden. Any comparator study, including cohort, case-control, and randomised controlled studies, will be included, both retrospective or prospective in nature. Studies conducted from any region in the world and involving any age of patient will be included. We will collect data on any morbidity outcomes, health-related quality of life measures, or health economic assessments reported. We predict a high heterogeneity in these outcomes used and will therefore keep inclusion criteria broad.

Discussion

Previous reviews have shown the significant improvements that can be achieved in mortality outcomes with the implementation of an organised trauma system, however the wider impact they can have on morbidity outcomes, quality of life measures, and the economic burden of trauma, is less well described. This systematic review will present all available data on these outcomes, helping to better characterise both the societal and economic impact of trauma system implementation.

Highlights

Trauma systems are known to improve mortality rates, however less in known on the impact they have on morbidity outcomes, quality of life, and economic burdenWe aim to perform a systematic review to identify any comparator study that assesses the impact implementation of a trauma system on these outcomesUnderstanding the impact trauma systems can have on wider parameters, such as economic and quality of life outcomes, is crucial to allow governments globally to appropriately allocate often limited healthcare resources.PROSPERO registration number: CRD42022348529.

Improving Timely Antibiotic Administration for Pediatric Oncology Patients With Neutropenic Fever Seen in the Emergency Department

OBJECTIVE

To improve the care for pediatric oncology patients with neutropenic fever who present to the emergency department (ED) by administering appropriate empiric antibiotics within 60 minutes of arrival.

PATIENTS AND METHODS

We focused on improving the care for pediatric oncology patients at risk of neutropenia who presented to the ED with concern for fever. Our baseline adherence to the administration of empiric antibiotics within 60 minutes for this population was 53% (76/144) from January 1, 2010, to December 21, 2014. During 2015, we reviewed data monthly, finding 73% adherence. We used the Lean methodology to identify the process waste, completed a value-stream map with input from multidisciplinary stakeholders, and convened a root cause analysis to identify causes for delay. The 4 causes were as follows: (1) lack of staff awareness; (2) missing patient information in electronic medical record; (3) practice variation; and 4) lack of clear prioritization of laboratory draws. We initiated Plan-Do-Study-Act cycles to achieve our goal of 80% of patients receiving appropriate empiric antibiotics within 60 minutes of arrival in the ED.

RESULTS

Five Plan-Do-Study-Act cycles were completed, focusing on the following: (1) timely identification of patients by utilizing the electronic medical record to initiate a page to the care team; (2) creation of a streamlined intravascular access process; (3) practice standardization; (4) convenient access to appropriate antibiotics; and (5) care team education. Timely antibiotic administration increased from 73%-95% of patients by 2018. More importantly, the adherence was sustained to greater than 90% through 2021.

CONCLUSION

A structured and multifaceted approach using quality improvement methodologies can achieve and sustain improved patient care outcomes in the ED.

Comparison of emergency department throughput and process times between male and female patients: A retrospective cohort investigation by the Reducing Disparities Increasing Equity in Emergency Medicine Study Group

Introduction

Health equity for all patients is an important characteristic of an effective healthcare system. Bias has the potential to create inequities. In this study, we examine emergency department (ED) throughput and care measures for sex‐based differences, including metrics such as door‐to‐room (DTR) and door‐to‐healthcare practitioner (DTP) times to look for potential signs of systemic bias.

Methods

We conducted an observational cohort study of all adult patients presenting to the ED between July 2015 and June 2017. We collected ED operational, throughput, clinical, and demographic data. Differences in the findings for male and female patients were assessed using Poisson regression and generalized estimating equations (GEEs). A priori, a clinically significant time difference was defined as 10 min.

Results

A total of 106,011 adult visits to the ED were investigated. Female patients had 8‐min longer median length‐of‐stay (LOS) than males (P < 0.01). Females had longer DTR (2‐min median difference, P < 0.01), and longer DTP (5‐min median difference, P < 0.01). Females had longer median door‐to‐over‐the‐counter analgesia time (84 vs. 80, P = 0.58), door‐to‐advanced analgesia (95 vs. 84, P < 0.01), door‐to‐PO (by mouth) ondansetron (70 vs. 62, P = 0.02), and door‐to‐intramuscular/intravenous antiemetic (76 vs. 69, P = 0.02) times compared with males.

Conclusion

Numerous statistically significant differences were identified in throughput and care measures—mostly these differences favored male patients. Few of these comparisons met our criteria for clinical significance.

Resuscitation code status among emergency department patients: decision support education video pilot study

Objectives

Establishment of code status can be challenging in the acute care setting. The primary objective of the present study was to evaluate whether patients or their surrogate decision-makers were comfortable watching an educational video about resuscitation.

Methods

This interventional pilot study involved a pre- and a postintervention survey of a convenience sample of emergency department (ED) patients who were admitted to the hospital. The study was conducted at an academic level-1 trauma centre within the normal flow of patient care over 4 months in 2017.

Results

In total, 50 patients enrolled in the study. Among them, 82% were ‘very comfortable’ and 14% were ‘moderately comfortable’ watching the video. Overall, 61% of respondents were ‘very comfortable’ recommending the video to others. Watching the video resulted in a change in code status for 9 patients.

Conclusions

Our results indicate that patients felt comfortable watching the video and recommending the video for further use. Watching the video did not result in a change in code status for most patients in this study. The study results indicate that a standardised patient education video on resuscitation code status was acceptable to patients and their family members and has potential for increased use in the ED.

Paths of Emergency Department Care: Development of a Decision Aid to Facilitate Shared Decision Making in Goals of Care Discussions in the Acute Setting

Background

Goals of care (GOC) conversations in the emergency department (ED) are often a brief discussion of code status rather than a patient-oriented dialogue. We aimed to develop a guide to facilitate conversations between ED clinicians and patients to elicit patient values and establish goals for end-of-life care, while maintaining ED efficiency. Paths of ED Care, a conversation guide, is the product of this work.

Design

A multidisciplinary/multispecialty group used recommended practices to adapt a GOC conversation guide for ED patients. ED clinicians used the guide and provided feedback on content, design, and usability. Patient-clinician interactions were recorded for discussion analysis, and both were surveyed to inform iterative refinement. A series of discussions with patient representatives, multidisciplinary clinicians, bioethicists, and health care designers yielded feedback. We used a process similar to the International Patient Decision Aid Standards and provide comparison to these.

Results

A conversation guide, eight pages with each page 6 by 6 inches in dimension, uses patient-oriented prompts and includes seven sections: 1) evaluation of patient/family understanding of disease, 2) explanation of possible trajectories, 3) introduction to different pathways of care, 4) explanation of pathways, 5) assessment of understanding and concerns, 6) code status, and 7) personalized summary.

Limitations

Recruitment of sufficient number of patients/providers to the project was the primary limitation. Methods are limited to qualitative analysis of guide creation and feasibility without quantitative analysis.

Conclusions

Paths of ED Care is a guide to facilitate patient-centered shared decision making for ED patients, families, and clinicians regarding GOC. This may ensure care concordant with patients’ values and preferences. Use of the guide was well-received and facilitated meaningful conversations between patients and providers.

Incorporating RTLS-Based Spatiotemporal Information in Studying Physical Activities of Clinical Staff. Annu Int Conf IEEE Eng Med Biol Soc 2021;2021:2386-2391. [PMID: 34891762 DOI: 10.1109/embc46164.2021.9630597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Clinicians and staff who work in intense hospital settings such as the emergency department (ED) are under an extended amount of mental and physical pressure every day. They may spend hours in active physical pressure to serve patients with severe injuries or stay in front of a computer to review patients' clinical history and update the patients' electronic health records (EHR). Nurses on the other hand may stay for multiple consecutive days of 9-12 working hours. The amount of pressure is so much that they usually end up taking days off to recover the lost energy. Both of these extreme cases of low and high physical activities are shown to affect the physical and mental health of clinicians and may even lead to fatigue and burnout.In this study Real-Time location systems (RTLS) are used for the first time, to study the amount of physical activity exerted by clinicians. RTLS systems have traditionally been used in hospital settings for locating staff and equipment, whereas our proposed method combines both time and location information together to estimate the duration, length, and speed of movements within hospital wards such as the ED. It is also our first step towards utilizing non-wearable devices to measure sedentary behavior inside the ED. This information helps to assess the workload on the care team and identify means to reduce the risk of performance compromise, fatigue, and burnout.We used one year worth of raw RFID data that covers movement records of 38 physicians, 13 residents, 163 nurses, 33 staff in the ED. We defined a walking path as the continuous sequences of movements and stops and identified separate walking paths for each individual on each day. Walking duration, distance, and speed, along with the number of steps and the duration of sedentary behavior, are then estimated for each walking path. We compared our results to the values reported in the literature and showed despite the low spatial resolution of RTLS, our non-invasive estimations are closely comparable to the ones measured by Fitbit or other wearable pedometers.Clinical Relevance- Adequate assessment of workload in a dynamic care delivery space plays an important role in ensuring safe and optimal care delivery [7]. Systems capable of measuring physical activities on a continuous basis during daily work can provide precious information for a variety of purposes including automated assessment of sedentary behaviors and early detection of work pressure. Such systems could help facilitate targeted changes in the number of staff, duration of their working shifts leading to a safer and healthier environment for both clinicians and patients.

Sex-based differences in timely emergency department evaluations for patients with drug poisoning

OBJECTIVES

Unintentional poisoning was the leading cause of injury-related death in the United States in 2017. Prescribed and illicit drugs are the most common cause of poisoning, and timely management in the emergency department (ED) is important. Our aim was to identify any disparities in wait times associated with sex for drug poisoning-related ED visits.

STUDY DESIGN

We examined ED visits using data from the 2009-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS).

METHODS

Drug poisoning-related visits were identified using the International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification codes. Delayed assessment was defined as wait times exceeding the recommended triage time. Weighted logistic regression was used.

RESULTS

The average age was 36 years (standard error = 1.1), 54% female, 87% White and 29% had delayed assessment. Most common drugs were psychotropics (45%) and opioids (32%). Adjusting for race, payment source, urgency, multiple drug types and NSAIDs, females who had poisoning by substances other than opioids had 2.1 times higher likelihood of having a delayed assessment compared with males (odds ratio [95% confidence interval]: 2.1 [1.03-4.2]), although there was no difference between sexes among visits with opioid poisoning (P = 0.27). Neither race (P = 0.23) nor payment source (P = 0.22) were associated with delayed assessment, and the sex association was consistent across these groups.

CONCLUSIONS

Females with non-opioid drug poisoning were more likely to have delayed assessment than men. None of the other demographic factors demonstrated a correlation. Identifying more populations vulnerable to delays in the ED can help guide the development of interventions and policies to expedite care and attenuate existing disparities.

A Comprehensive Departmental Care Review Model: Requirements, Structure, and Flow

BACKGROUND

The Institute of Medicine, the National Patient Safety Foundation, and The Joint Commission have advocated for increased systematic care review to inform future quality improvement. Developing a system to efficiently gather meaningful feedback, review care, and identify areas for improvement can take years to construct. Yet, these systems are vital to reducing future medical error.

CONTEXT, HISTORY, AND DEVELOPMENT

In this article, the authors present a refined intradepartmental system of retrospective care review. The team created and iteratively improved this model for more than 10 years. Herein, key aspects and benefits of the system are described.

CARE REVIEW SYSTEM

A successful care review system should include a broad catchment for cases to review, direct input from multidisciplinary staff involved in each case, a standardized evaluation and feedback process, a system to translate identified gaps into practice improvement, and development of a psychologically safe space for discussions to occur. Resources required to build this system include a quality specialist, a panel of physician and nurse reviewers, and administrative assistance. Blinding cases and electronic blinded polling technology can enhance participation and reduce bias in case assessment.

CONCLUSION

The authors believe that this process for care review can help hospital systems of varying resource levels produce high-quality case review and thereby activate practice improvement to prevent downstream medical errors.

The Hidden Cost of Hemolyzed Blood Samples in the Emergency Department

BACKGROUND

On average, patients with hemolyzed potassium samples spend about 1 h longer in the emergency department (ED), regardless of acuity level or disposition. We aimed to quantify the direct expenses associated with poor-quality preanalytic blood samples collected in the ED.

METHODS

We created a simple table with a range of direct expenses (i.e., costs) and rates of hemolyzed sample draws, allowing for identification of potential high-level cost-of-care impact analysis. We included a range of costs informed by review of literature on the topic. Those costs range from $600 to $3000 per bed-hour. This amount was inflation adjusted from 1996 to 2020 (1.68 × [direct cost per visit] × [100 000 visits per year/365 days/24 h]). We provided a range of hemolysis incidence based on previously reported data.

RESULTS

We showed that for an ED with 100 000 annual visits, a 40% draw rate for routine chemistries (including potassium), and a 10% hemolysis incidence, the direct cost impact of hemolysis waste is approximately $4 million/year as a result of the 1 h of added length of stay on average for a patient with a hemolyzed blood sample. This amount represents an annualized estimated cost of caring for a patient in the ED with an avoidable extended length of stay.

CONCLUSIONS

The financial burden of poor-quality blood samples can be estimated using cost per bed-hour and rate of sample failure. Similar methodology may identify additional QC issues with previously invisible financial implications.

Impact of the SARS-CoV-2 Pandemic on Emergency Department Presentations in an Integrated Health System

OBJECTIVE

To quantify the impact of the severe acute respiratory syndrome coronavirus 2 pandemic on emergency department volumes and patient presentations and evaluate changes in community mortality for the purpose of characterizing new patterns of emergency care use.

PATIENTS AND METHODS

This is an observational cross-sectional study using electronic health records for emergency department visits in an integrated multihospital system with academic and community practices across 4 states for visits between March 17 and April 21, 2019, and February 9 and April 21, 2020. We compared numbers and proportions of common and critical chief symptoms and diagnoses, triage assessments, throughput, disposition, and selected hospital lengths of stay and out-of-hospital deaths.

RESULTS

In the period of interest, emergency department visits decreased by nearly 50% (35037 to 18646). Total numbers of patients with myocardial infarctions, stroke, appendicitis, and cholecystitis diagnosed decreased. The percentage of visits for mental health symptoms increased. There was an increase in deaths, driven by out-of-hospital mortality.

CONCLUSION

Fewer patients presenting with acute and time-sensitive diagnoses suggests that patients are deferring care. This may be further supported by an increase in out-of-hospital mortality. Understanding which patients are deferring care and why will allow us to develop outreach strategies and ensure that those in need of rapid assessment and treatment will do so, preventing downstream morbidity and mortality.

Palliative care in the emergency department: A survey assessment of patient and provider perspectives

BACKGROUND

Palliative care has been identified as an area of low outpatient referral from our emergency department, yet palliative care has been shown to improve the quality of patient's lives.

AIM

This study investigates both provider and patient perspectives on palliative care for the purpose of identifying barriers to increased palliative care utilization within our healthcare system.

DESIGN

Two surveys were developed, one for patients/caregivers and one for healthcare providers.

SETTING/PARTICIPANTS

This was a single-center study completed at a quaternary academic emergency department. A survey was sent to emergency medicine providers with 47% response rate. Research staff approached Emergency Department patients who had been identified to be high risk to fill out paper surveys with 76% response rate.

RESULTS

Only 28% of patients had already undergone palliative care, with an additional 25% interested in palliative care. Nearly half of the patients felt that they needed more resources to prevent hospital visits. Patients identified low understanding of palliative care and difficulty accessing appointments as barriers to consultation. Among providers, 98% indicated that they had patients who would benefit from palliative care. A majority of providers highlighted patient understanding of palliative care and access to appointments as barriers to palliative care. Notably, 52% of providers reported that emergency medicine provider knowledge was a barrier to palliative care consultation.

CONCLUSIONS

Despite emergency department patients' self-identified need for resources and emergency medicine providers' recognition of patients who would benefit from palliative care, few patients receive palliative care consultation.

Non-pharmacologic interventions improve comfort and experience among older adults in the Emergency Department

OBJECTIVE

Determine if a comfort cart would improve older adults' comfort and facilitate communication during Emergency Department (ED) visits.

METHODS

A comfort cart containing low-cost, non-pharmacological interventions to improve patient comfort and ability to communicate (e.g., hearing amplifiers, reading glasses) were made available to patients aged ≥65 years. Patients and clinicians were surveyed to assess effectiveness. We followed the Standards for Quality Improvement Reporting Excellence: SQUIRE 2.0 guidelines.

RESULTS

Three hundred patients and 100 providers were surveyed. Among patients, 98.0%, 95.1%, and 67.5% somewhat or strongly agreed that the comfort cart improved comfort, overall experience, and independence, respectively. Among providers, 97.0%, 95.0%, 87.0%, and 83% somewhat or strongly agreed that the comfort cart provided comfort, improved patient satisfaction, increased ability to give compassionate care, and increased patient orientation.

CONCLUSION

The comfort cart was an affordable and effective intervention that improved patients' comfort by facilitating communication, wellbeing, and compassionate care delivery.

Interventions to improve older adults' Emergency Department patient experience: A systematic review

STUDY OBJECTIVE

To summarize interventions that impact the experience of older adults in the emergency department (ED) as measured by patient experience instruments.

METHODS

This is a systematic review to evaluate interventions aimed to improve geriatric patient experience in the ED. We searched Ovid CENTRAL, Ovid EMBASE, Ovid MEDLINE and PsycINFO from inception to January 2019. The main outcome was patient experience measured through instruments to assess patient experience or satisfaction. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the confidence in the evidence available.

RESULTS

The search strategy identified 992 studies through comprehensive literature search and hand-search of reference lists. A total of 21 studies and 3163 older adults receiving an intervention strategy aimed at improve patient experience in the ED were included. Department-wide interventions, including geriatric ED and comprehensive geriatric assessment unit, focused care coordination with discharge planning and referral for community services, were associated with improved patient experience. Providing an assistive listening device to those with hearing loss and having a pharmacist reviewing the medication list showed an improved patient perception of quality of care provided. The confidence in the evidence available for the outcome of patient experience was deemed to be very low.

CONCLUSION

While all studies reported an outcome of patient experience, there was significant heterogeneity in the tools used to measure it. The very low certainty in the evidence available highlights the need for more reliable tools to measure patient experience and studies designed to measure the effect of the interventions.

Validation of the Elderly Risk Assessment Index in the Emergency Department

OBJECTIVES

The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients.

METHODS

Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85).

CONCLUSION

The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.

Validation of the Elderly Risk Assessment Index in the Emergency Department

OBJECTIVES

The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients.

METHODS

Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85).

CONCLUSION

The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.

Progression of Emergency Medicine Resident Patient Experience Scores by Level of Training

Background:

Patient satisfaction surveys are vital to measuring a patient’s experience of care. How scores of patients managed by emergency medicine (EM) residents change as residents progress through training is not known.

Objectives:

To evaluate whether EM residents’ patient satisfaction scores improve as residency training progresses, similar to clinical skill improvement.

Methods:

A retrospective cross-sectional study evaluated the correlation of patient satisfaction scores with EM resident year of training from 2015 through 2017. We evaluated for a change in score over time for the 4 “physician questions” and the “overall” score.

Results:

We evaluated 1684 Press Ganey surveys linked to 40 EM resident physicians during the study period. The mean top box scores for the 4 physician questions (concern for comfort [P = .72], courtesy [P = .55], informative about treatment [P = .46], and listening [P = .91]) and overall assessment of emergency department care (P = .51) were not significantly improved over the course of resident.

Conclusion:

We did not observe a difference in EM residents’ patient experience scores as their level of training progressed. Comprehensive patient experience training for residents might be needed.

Ongoing and Focused Provider Performance Evaluations in Emergency Medicine: Current Practices and Modified Delphi to Guide Future Practice

The Joint Commission requires ongoing and focused provider performance evaluations (OPPEs/FPPEs). The authors aim to describe current approaches in emergency medicine (EM) and identify consensus-based best practice recommendations. An online survey was distributed to leaders in EM to gain insight into current practices. A modified Delphi approach was then used to develop consensus to recommend best practice. A variety of strategies are currently in use for OPPE/FPPE. “Peer reviewed cases with opportunity for improvement” was identified as a preferred metric for OPPE. Although the preference was for use of peer review in OPPE, a consistent and standard adoption of robust internal care review processes is needed to establish expected norms. National benchmarking is not available currently. This was a limited survey of self-identified leaders, and there is an opportunity for additional engagement of leaders in EM to identify a unified approach that appropriately relates to patient outcomes.

Anti-factor Xa Monitoring and Activated Charcoal for a Pediatric Patient With Rivaroxaban Overdose

Rivaroxaban, an oral anticoagulant, directly inhibits factor Xa (FXa). A 35-month-old boy was brought to the emergency department 15 minutes after ingesting 200 mg of rivaroxaban (16 mg/kg). Activated charcoal (AC) was administered; the patient was observed with monitoring of plasma anti-FXa levels and discharged the following day after an uneventful hospital observation. We identified two case series and seven case reports of potentially toxic rivaroxaban ingestion in the literature. No serious adverse effects were reported. The present case is the first reported use of anti-FXa monitoring after rivaroxaban ingestion. The magnitude of the effect of AC administration in this patient is unclear.

Clinical care review systems in healthcare: a systematic review

Background

Clinical care review is the process of retrospectively examining potential errors or gaps in medical care, aiming for future practice improvement. The objective of our systematic review is to identify the current state of care review reported in peer-reviewed publications and to identify domains that contribute to successful systems of care review.

Methods

A librarian designed and conducted a comprehensive literature search of eight electronic databases. We evaluated publications from January 1, 2000, through May 31, 2016, and identified common domains for care review. Sixteen domains were identified for further abstraction.

Results

We found that there were few publications that described a comprehensive care review system and more focus on individual pathways within the overall systems. There is inconsistent inclusion of the identified domains of care review.

Conclusion

While guidelines for some aspects of care review exist and have gained traction, there is no comprehensive standardized process for care review with widespread implementation.

Electronic supplementary material

The online version of this article (10.1186/s12245-018-0166-y) contains supplementary material, which is available to authorized users.

Gender Distribution Among American Board of Medical Specialties Boards of Directors

Since 1995, women have comprised more than 40% of all medical school graduates. However, representation at leadership levels in medicine remains considerably lower. Gender representation among the American Board of Medical Specialties (ABMS) boards of directors (BODs) has not previously been evaluated. Our objective was to determine the relative representation of women on ABMS BODs and compare it with the in-training and in-practice gender composition of the respective specialties. The composition of the ABMS BODs was obtained from websites in March 2016 for all Member Boards. Association of American Medical Colleges and American Medical Association data were utilized to identify current and future trends in gender composition. Although represented by a common board, neurology and psychiatry were evaluated separately because of their very different practices and gender demographic characteristics. A total of 25 specialties were evaluated. Of the 25 specialties analyzed, 12 BODs have proportional gender representation compared with their constituency. Seven specialties have a larger proportion of women serving on their boards compared with physicians in practice, and 6 specialties have a greater proportion of men populating their BODs. Based on the most recent trainee data (2013), women have increasing workforce representation in almost all specialties. Although women in both training and practice are approaching equal representation, there is variability in gender ratios across specialties. Directorship within ABMS BODs has a more equitable gender distribution than other areas of leadership in medicine. Further investigation is needed to determine the reasons behind this difference and to identify opportunities to engage women in leadership in medicine.

Personalized medicine approaches in epilepsy

Epilepsy affects 50 million persons worldwide, a third of whom continue to experience debilitating seizures despite optimum anti-epileptic drug (AED) treatment. Twelve-month remission from seizures is less likely in female patients, individuals aged 11-36 years and those with neurological insults and shorter time between first seizure and starting treatment. It has been found that the presence of multiple seizures prior to diagnosis is a risk factor for pharmacoresistance and is correlated with epilepsy type as well as intrinsic severity. The key role of neuroinflammation in the pathophysiology of resistant epilepsy is becoming clear. Our work in this area suggests that high-mobility group box 1 isoforms may be candidate biomarkers for treatment stratification and novel drug targets in epilepsy. Furthermore, transporter polymorphisms contributing to the intrinsic severity of epilepsy are providing robust neurobiological evidence on an emerging theory of drug resistance, which may also provide new insights into disease stratification. Some of the rare genetic epilepsies enable treatment stratification through testing for the causal mutation, for example SCN1A mutations in patients with Dravet's syndrome. Up to 50% of patients develop adverse reactions to AEDs which in turn affects tolerability and compliance. Immune-mediated hypersensitivity reactions to AED therapy, such as toxic epidermal necrolysis, are the most serious adverse reactions and have been associated with polymorphisms in the human leucocyte antigen (HLA) complex. Pharmacogenetic screening for HLA-B*15:02 in Asian populations can prevent carbamazepine-induced Stevens-Johnson syndrome. We have identified HLA-A*31:01 as a potential risk marker for all phenotypes of carbamazepine-induced hypersensitivity with applicability in European and other populations. In this review, we explore the currently available key stratification approaches to address the therapeutic challenges in epilepsy.

Dose-effect functions for cocaine self-administration: effects of schedule and dosing procedure

Research related to determining how procedural variables can alter dose-effect functions for cocaine self-administration is limited. Toward clarifying the role of procedural variables, responding was maintained in rats under either variable-interval (VI) or fixed-ratio (FR) schedules of cocaine infusion. In addition to free-operant FR schedules, discrete-trial FR schedules were evaluated. The dose-effect functions were obtained by either substituting a dose for the usual daily dose, instituting a particular dose for several sessions, or making all doses available within a session. Dose-effect functions for response rate (or number of trials with infusions for the discrete-trial FR) were bitonic for the VI and discrete-trial FR schedules but tended to be strictly decreasing for the free-operant FR schedules. Responding was maintained under FR schedules by a low dose (0.083 mg/infusion) if the dose was substituted for a higher daily dose but not when made available daily. Rate of response was higher under ratio schedules at 0.17 mg/infusion when this dose occurred within the context of other higher doses within a session than when the dose was simply substituted for a higher daily dose. These data indicate that procedural variables can alter dose-response curves for cocaine self-administration.

Bacterial Infections of Hemocytes Associated with the Maternally Inherited Male-Killing Trait in British Populations of the Two Spot Ladybird, Adalia bipunctata

Adalia bipunctata, the two spot ladybird, carries a vertically transmitted bacterial agent which kills male progeny during embryogenesis. Some matrilines of A. bipunctata give rise to strongly female-biased sex ratios. 16S rDNA sequence analysis revealed a bacterium of the genus Rickettsia associated with this trait, a conclusion which is corroborated here. Using light microscopy, an association between a bacterium located in A. bipunctata hemocyte cytoplasm and matrilines which show the sex ratio trait was found. This element was not found in hemocytes taken from females from normal sex ratio lines, nor in hemocytes taken from males. The association is confirmed by study of the inheritance of the sex ratio trait. Only daughters of sex ratio crosses that bear this cytoplasmic bacterium also show the sex ratio trait, with other daughters being normal with respect to sex ratio. Transmission electron microscopy of hemocytes revealed a walled bacterium, bearing features of members of the genus Rickettsia, free in the cytoplasm of hemocytes taken from infected lines, but not in those taken from uninfected lines.

Male-killing bacterium in a fifth ladybird beetle, Coleomegilla maculata (Coleoptera:Coccinellidae)

Inherited symbionts which selectively cause the death of male hosts are found widely across the Insecta. Previous studies have shown a single, but different micro-organism to be responsible for male-killing in each taxonomic group studied. We here produce evidence that within a group of insects, the Coccinellidae, there is more than one causal agent of male lethality. We report a novel observation of a male-killing trait in the species Coleomegilla maculata. Six of 26 crosses were found to produce a female-biased sex ratio associated with a low egg hatch-rate. The trait was matrilinearly inherited and was observed to be tetracycline-sensitive. However, tests which indicate the presence of a Rickettsia, previously found to cause male-killing in another member of the Coccinellidae, Adalia bipunctata, proved negative. We therefore conclude that the phenomenon of male-killing is multicausal, within, as well as between, taxonomic groups of the Insecta.

Within-session determination of dose-response curves for heroin self-administration in rats: Comparison with between-session determination and effects of naltrexone

A procedure was employed in the present study to obtain dose-response curves for heroin self-administration within each experimental session. The data generated using this procedure were compared to dose-response data obtained using between-session dose manipulations. The dose of heroin (18, 30, 60 or 100 micrograms/kg/inf) was varied across 4-hourly segments separated by a 20-min time-out period during which heroin was not available. The within-session dose-response procedure yielded data similar to those obtained using between-session dose manipulations when the order of dose presentation was increasing or random. However, the dose-response curve for total drug-intake was flat when the doses were presented in decreasing order. Further analysis of the dose-response curves in the within-session procedure demonstrated that the rate of heroin intake increased in the third and fourth hourly components compared to the first component, suggesting acute tolerance to the reinforcing and/or rate-suppressive effects of heroin. Furthermore, using a random order of dose presentation, administration of 3.0 mg/kg of naltrexone prior to the session shifted the dose-response curve for heroin self-administration 5-fold to the right in the within-session procedure. The data indicate that the within-session dose-response procedure can be used to investigate the pharmacology of heroin self-administration in rodents.

The French-line abdominoplasty

This study presents 50 consecutive cases of abdominoplasty utilizing the authors' French-line method. This technique incorporates the basic principles of more traditional abdominoplasty procedures with significant modifications that allow for more aggressive plication of the fascia for accentuation of the waistline and relatively short oblique lateral incisions that are easily concealed within the French-cut one-piece bathing suit or reasonably modest bikini. The technique lends itself to adjunctive intra-abdominal procedures such as cholecystectomy or hysterectomy and is a safe method of abdominal reconstruction following transverse rectus abdominis musculocutaneous flap breast reconstruction. Complications are no more frequent than with "traditional" techniques. The only absolute contraindication is the presence of chronic obstructive pulmonary disease; relative contraindications are the same as for other abdominoplasty procedures.

Diagnostic value of clinical examination and various imaging techniques for breast implant rupture as determined in 81 patients having implant removal

To determine sensitivity and specificity of magnetic resonance imaging (MRI) and ultrasonography (US) in the detection of breast implant rupture, and also to determine the relative merits of clinical examination and mammography, we studied 81 patients (160 implants). All patients had implants removed, thus allowing confirmation of the presence or absence of rupture. Clinical examination positively identified only one patient with implant rupture, and mammography detected only two implant ruptures (both extracapsular). The sensitivity for US was 70% and specificity was 90%, while for MRI it was 75.6% and 94%, respectively. These differences between MRI and US were not statistically significant. Combining the results of US and MRI did not seem to add to the diagnostic discrimination. The most cost-effective method of diagnosing implant rupture was US in our study.

Clinical relevance of positive breast periprosthetic cultures without overt infection

The true incidence of positive breast periprosthetic cultures in the absence of overt infection is not clearly established. We retrospectively reviewed data from 389 implants that were removed for reasons other than clinical infection. Many of these patients presented with a variety of musculoskeletal ailments. Others had symptomatic capsular contracture as the presenting complaint. In a few a known implant rupture was the reason for explantation. We identified a positive culture rate of 23.5 percent from capsule tissue. Most of these organisms were coagulase-negative staphylococci and anaerobic diphtheroids, but fungi and other organisms (generally felt to be more pathogenic than the less virulent coagulase-negative staphylococci) also were cultured. In an attempt to identify the clinical relevance of these positive cultures, we statistically evaluated the culture results for associations with capsular contracture, implant rupture, type of implant, and location of implant. Of these, the only statistically significant correlation was between positive culture result and symptomatic capsular contracture (Baker class IV).

Utility of magnetic resonance imaging and ultrasonography in diagnosing breast implant rupture

We prospectively evaluated 81 patients (with 160 implants) who subsequently had implants removed to determine sensitivity and specificity of both magnetic resonance imaging and ultrasonography. Positive and negative predictive values were also calculated to determine whether a statistically beneficial interaction existed when ultrasonography and magnetic resonance imaging were used in combination to examine an implant. Finally, the misdiagnoses were retrospectively evaluated to identify the pitfalls of the investigations. Positive diagnostic criteria were described. The sensitivity and specificity of ultrasonography were 47% and 83%, respectively, and of MRI, 46% and 88%, respectively. On retrospective review by the radiologist, the sensitivity and specificity of ultrasonography were 70% and 90%, respectively, and of magnetic resonance imaging, 75.6% and 94%, respectively. Although definite conclusions could not be obtained, there did not seem to be an additive benefit from using both ultrasonography and magnetic resonance imaging.

A review of 198 patients (389 implants) who had breast implants removed

Because of the large number of women now returning to their plastic surgeons with concerns about their breast implants many years after surgery, we are afforded an ideal opportunity to evaluate these patients over the long-term. This study reviewed 198 patients (389 implants) who underwent explantation by two surgeons over a 2-year period, correlating prosthesis type, location, and length of time since implantation with two adverse endpoints, implant rupture and symptomatic capsular contracture. Significant findings included a relatively high rate of implant rupture in patients whose implants had been in place over 20 years, an increased incidence of both symptomatic capsular contracture and implant rupture in single lumen gel implants and a positive correlation between severity of capsular contracture and implant rupture.

Structure--activity relationships of sialyl Lewis x-containing oligosaccharides. 1. Effect of modifications of the fucose moiety

Leukocyte adhesion to the vasculature is mediated by E-, P-, and L-selectins. The natural ligands for E- and P-selectins have not been fully characterized but have been shown to contain the tetrasaccharide sialyl Lewis x structure (SLe(x)). To determine the importance of the fucose moiety of SLe(x), various analogs of SLe(x) containing modifications thereof were prepared and tested as inhibitors of E-selectin-mediated cell adhesion. Cellular experiments indicate that replacement of the hydroxyl groups of fucose by hydrogen abrogated E-selectin binding. However, the arabinose analog of fucose (CH3 delta H) inhibited cell adhesion but was 5-fold less potent than native SLe(x). This data suggests that modifications of fucose on SLe(x) are generally deleterious toward E-selectin binding.

Monoclonal antibody KS1/4-methotrexate immunoconjugate studies in non-small cell lung carcinoma

The antigen reactive with murine monoclonal antibody (MAb) KS1/4 is expressed on epithelial malignancies and some normal epithelial tissues. Studies were undertaken to evaluate KS1/4-methotrexate (KS1/4-MTX) immunoconjugate in patients with advanced non-small cell carcinoma of the lung. Eleven patients in two different groups received KS1/4-MTX in two different escalating dose infusion schedules with a maximal tolerated dose of 1,750 mg/M2 and a cumulative dose of MTX of 40 mg/M2. Toxicities were similar in both groups and included fever, anorexia, nausea, vomiting, diarrhea, abdominal pain, guaiac positive stool, and hypoalbuminemia. Two patients had an associated aseptic meningitis. One patient had a 50% decrease in two lung nodules without a change in lymphangitic infiltrates. This patient received a second course of treatment and developed an immune complex-mediated arthritis and serum sickness. Four patients mounted a human antimouse antibody response. Post-treatment tumor biopsies documented binding of MAb KS1/4. These studies document the feasibility and potential usefulness of a MAb directed against tumor-associated antigens with the targeting of chemotherapeutic drugs in patients with non-small cell lung carcinoma.

cDNA cloning and immunological characterization of the rye grass allergen Lol p I

The complete amino acid sequence of two "isoallergenic" forms of Lol p I, the major rye grass (Lolium perenne) pollen allergen, was deduced from cDNA sequence analysis. cDNA clones isolated from a Lolium perenne pollen library contained an open reading frame coding for a 240-amino acid protein. Comparison of the nucleotide and deduced amino acid sequence of two of these clones revealed four changes at the amino acid level and numerous nucleotide differences. Both clones contained one possible asparagine-linked glycosylation site. Northern blot analysis shows one RNA species of 1.2 kilobases. Based on the complete amino acid sequence of Lol p I, overlapping peptides covering the entire molecule were synthesized. Utilizing these peptides we have identified a determinant within the Lol p I molecule that is recognized by human leukocyte antigen class II-restricted T cells obtained from persons allergic to rye grass pollen.

Biosynthesis and glycosylation of the carcinoma-associated antigen recognized by monoclonal antibody KS1/4

Monoclonal antibody KS1/4 recognizes an epitope expressed on the cell surface of human adenocarcinoma cells and certain epithelia. Western blotting analyses of tumor cell extracts utilizing KS1/4 reveal staining of a major Mr 40,000 band and a minor Mr 42,000 band. Both components are also detectable in KS1/4 immunoprecipitates of L-[35S]methionine- and D-[3H]glucosamine-labeled human lung tumor cell extracts. When synthesis occurs in the presence of tunicamycin or when the immunoprecipitates are treated with peptide:N-glycosidase F, a single polypeptide component (Mr 37,000) is precipitated. Immediately following translation, digestion of Mr 40,000 and Mr 42,000 glycoproteins with endo-beta-N- acetylglucosaminidase H also yields a single polypeptide component at Mr 37,000. However, over a 3-h period beginning at 10 min posttranslation, a Mr 39,000 major component and a Mr 41,000 minor component gradually appear in the endo-beta-N-acetylglucosaminidase H digests as the Mr 37,000 component gradually disappears. Analysis of tryptic glycopeptides derived from the Mr 40,000 and 42,000 components suggests that the two components differ by the addition of one extra oligosaccharide to the Mr 42,000 component. Nonequilibrium pH gradient electrophoresis/sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis of KS1/4 immunoprecipitates resolves each of the two components into multiple spots. Digestion of the KS1/4 immunoprecipitates with neuraminidase prior to two-dimensional analysis or immunoprecipitation of short pulse-labeled extracts reduces the number of spots to three each at the Mr 40,000 and Mr 42,000 positions. Digestion of the KS1/4 immunoprecipitates with peptide:N-glycosidase F, immunoprecipitation of extracts labeled in the presence of tunicamycin, or endo-beta-N-acetylglucosaminidase H digestion of immunoprecipitates of short pulse-labeled extracts prior to two-dimensional analysis results in a single series of Mr 37,000 spots, suggesting that the polypeptide portions of the Mr 40,000 and Mr 42,000 components may be identical. Endo-beta-N-acetylglucosaminidase H digestion of KS1/4 immunoprecipitates of short pulse-labeled extracts, followed by nonequilibrium pH gradient electrophoresis, V8 protease digestion, and polyacrylamide gel electrophoresis revealed an apparently identical set of polypeptides derived from each of the three Mr 37,000 spots, suggesting that the three spots derive from highly similar polypeptides.

Phase I clinical comparative study of monoclonal antibody KS1/4 and KS1/4-methotrexate immunconjugate in patients with non-small cell lung carcinoma

A Phase Ia clinical trial was undertaken to evaluate and compare murine monoclonal antibody KS1/4 and KS1/4-methotrexate immunoconjugate in patients with Stage IIIB or IV non-small cell carcinoma of the lung. Six patients received KS1/4 alone and five patients received KS1/4-methotrexate conjugate. The maximal total dose received per patient in both groups was 1661 mg. Mild to moderate side effects in both groups included fever, chills, anorexia, nausea, vomiting, diarrhea, anemia, and brief transaminasemia. One patient who received antibody alone had an apparent acute immune complex-mediated reaction. Ten of 11 patients had a human anti-mouse response. Posttreatment carcinoma biopsies revealed binding of monoclonal antibody KS1/4 and deposition of C3d and C4c complement fragments. Monoclonal antibody binding and complement deposition correlated with increasing doses of infused antibody. There was one possible clinical response.

Isolation and characterization of a cDNA encoding the KS1/4 epithelial carcinoma marker

The mAb KS1/4 recognizes a novel cell surface glycoprotein on a variety of epithelial carcinomas which may be a useful target Ag for antibody-directed diagnostic and therapeutic approaches. Here we report the isolation and characterization of a full length cDNA clone coding for the KS1/4 Ag, as well as, physical and biochemical studies on the antigen derived from an adenocarcinoma of the lung cell line. Affinity purification of the KS1/4 Ag reveals three glycosylated species by NaDodSO4 PAGE with molecular weights of 42, 40, and 35 kDa. The 42- and 40-kDa species are similar at the protein level, differing by their degree of glycosylation, and the 35-kDa protein results from a dibasic proteolytic cleavage of the larger m.w. species. Although both the 42- and 40-kDa forms are found on the cell surface, the 40-kDa protein appears to be the predominant species. A cDNA clone containing the complete KS1/4 coding sequence and the 5'- and 3'-non-translated regions was isolated from a library constructed from the human adenocarcinoma of the lung derived cell line, UCLA-P3. The cDNA clone contains an open reading frame of 314 amino acids which includes a putative signal sequence of 23 amino acids. Northern blot analysis shows a single RNA species of 1.5-kb. Sequence analysis of the 5' and 3' noncoding regions of the KS1/4 cDNA revealed homologies to known proto-oncogenes and inflammatory mediators.

Isolation and characterization of a cDNA encoding the KS1/4 epithelial carcinoma marker

The mAb KS1/4 recognizes a novel cell surface glycoprotein on a variety of epithelial carcinomas which may be a useful target Ag for antibody-directed diagnostic and therapeutic approaches. Here we report the isolation and characterization of a full length cDNA clone coding for the KS1/4 Ag, as well as, physical and biochemical studies on the antigen derived from an adenocarcinoma of the lung cell line. Affinity purification of the KS1/4 Ag reveals three glycosylated species by NaDodSO4 PAGE with molecular weights of 42, 40, and 35 kDa. The 42- and 40-kDa species are similar at the protein level, differing by their degree of glycosylation, and the 35-kDa protein results from a dibasic proteolytic cleavage of the larger m.w. species. Although both the 42- and 40-kDa forms are found on the cell surface, the 40-kDa protein appears to be the predominant species. A cDNA clone containing the complete KS1/4 coding sequence and the 5'- and 3'-non-translated regions was isolated from a library constructed from the human adenocarcinoma of the lung derived cell line, UCLA-P3. The cDNA clone contains an open reading frame of 314 amino acids which includes a putative signal sequence of 23 amino acids. Northern blot analysis shows a single RNA species of 1.5-kb. Sequence analysis of the 5' and 3' noncoding regions of the KS1/4 cDNA revealed homologies to known proto-oncogenes and inflammatory mediators.

Psychology and violence against women

The discipline of psychology has made many contributions to the understanding of the social problem of men's violence against women during the past 15 years by reframing the problem as one of misuse of power by men who have been socialized into believing they are entitled to control the women in their lives, even by violent means. The new scientific psychology data base formed by integrating feminist gender analysis methods into more traditional psychological methodology is discussed, as are the implications of the resulting empirical data on which are based newer assessment, treatment, and forensic applications. A review of the major psychological advances in psychotherapy with women who have been sexual assaulted, exploited, and battered is presented, as well as implications for national policy. The feminist model presented is one in which science and practice concerns are carefully considered at all steps of the process. The article concludes with a discussion of the challenges involved in making the future training of psychologists more relevant to women's mental health concerns.

Psychology and violence against women

The discipline of psychology has made many contributions to the understanding of the social problem of men's violence against women during the past 15 years by reframing the problem as one of misuse of power by men who have been socialized into believing they are entitled to control the women in their lives, even by violent means. The new scientific psychology data base formed by integrating feminist gender analysis methods into more traditional psychological methodology is discussed, as are the implications of the resulting empirical data on which are based newer assessment, treatment, and forensic applications. A review of the major psychological advances in psychotherapy with women who have been sexual assaulted, exploited, and battered is presented, as well as implications for national policy. The feminist model presented is one in which science and practice concerns are carefully considered at all steps of the process. The article concludes with a discussion of the challenges involved in making the future training of psychologists more relevant to women's mental health concerns.