The Extent and Effects of Abuse and Harassment of Emergency Medicine Residents

OBJECTIVE: To determine the extent and effects of abuse and harassment, including sexual harassment and racial or ethnic discrimination, experienced by residents in emergency medicine (EM). METHOD: The study instrument was an anonymous, self-report survey administered to a national sample of EM residents. The survey was timed to coordinate with the American Board of Emergency Medicine's annual In-Service Examination in February 1993. The residents reported whether they had experienced nine types of abuse or harassment during their residency training, the sources of these incidents, the effects on the residents, and whether they chose to file a formal complaint regarding these events. RESULTS: Surveys were returned by 1,774 (80%) of the 2,229 residents who sat for the examination--74.4% men and 24.6% women. Overall, 98% reported at least one occurrence of abuse or harassment, with patients being the most frequent source. More than half of the more senior residents reported having been physically hit or pushed. Other health care professionals were a frequent source of verbal abuse and sexual harassment. Women were significantly more likely than men to report unwanted sexual advances (63% vs 32%, p < 0.001), discomfort from sexual humor (66% vs 27%, p < 0.001), and unfair treatment because of gender (71% vs 15%, p < 0.001). Non-Caucasians reported a higher rate of racial or ethnic discrimination than did Caucasians (51% vs 23%, p < 0.001). As a result of these episodes, 19% of the respondents had questioned their decision to become a physician, 20% had questioned entering the specialty of EM, 11% had experienced emotional effects lasting over one month, and 11% had experienced disruption of their family lives. Only 56 (3.2%) had filed formal complaints. CONCLUSIONS: Residents frequently encounter abuse or harassment, particularly from patients. They also report adverse consequences from these episodes.     

Detection of Undiagnosed Coeliac Disease with Atypical Features Using Antireticulin and Antigliadin Antibodies

Eighteen patients with a variety of non-gastrointestinal symptomswere incidentally found to have circulating antireticulin antibodyand on subsequent testing were also positive for antigliadinantibody. They prospectively underwent jejunal biopsy to determinewhether or not they had coeliac disease. Their age range was21–79 years (mean 42 years). Enteropathy was present in13 (72 per cent) and was always associated with circulatingIgA antigliadin antibody. Enteropathy was not present in thefive cases who had only IgG antibody. Clinical improvement occurredin eight of 11 patients who complied with a gluten-free dietand was paralleled by an improvement in the mucosal histologyin seven of eight who were re-biopsied. The most remarkablecases were two patients who presented with severe debility andno apparent haematological or biochemical abnormalities, andwho subsequently made a dramatic recovery on a gluten-free diet.It is concluded that antireticulin antibody detected by routineautoantibody screening and confirmed to have IgA antigliadinantibody specificity is a useful indicator of an otherwise undiagnosedenteropathy. This serves to emphasize that the condition cansometimes be associated with atypical features and significantmorbidity.     

A Survey of Oregon Emergency Physicians to Assess Mandatory Reporting Knowledge and Reporting Patterns Regarding Intoxicated Drivers in the State of Oregon

Objectives: To assess emergency physician reporting patterns in Oregon before and after the passage of a mandatory intoxicated driving reporting law. Methods: A one‐page survey was mailed to 504 emergency physicians in Oregon in April 2004. Data on reporting frequency were collected using a four‐point ordinal scale regarding motor vehicle crash–involved drivers (MIDs) and intoxicated persons attempting to drive away from the emergency department (DAEDs). Paired observations were assessed for a stated increase in reporting activity following passage of the law using the Wilcoxon signed‐rank test. Associations of postlaw reporting and demographic and knowledge factors were sought using Spearman rank correlation analysis. Results: Of the 504 surveys mailed, 298 (59%) were adequate for analysis. Many respondents (57%) were already aware of the law. Most (92%) agreed that physicians should be mandated to report some crimes. MIDs were always reported by 18% of physicians before the law and by 47% afterward, whereas DAEDs were always reported by 56% of physicians before the law and by 69% afterward. Emergency medicine–trained physicians, higher emergency department census, and increased years of experience were associated with a significantly higher increase in reporting pattern after passage of the law for both MIDs and DAEDs. Conclusions: Although 44% of responding emergency physicians in Oregon were unaware of a mandated reporting law for intoxicated drivers presenting to the ED, most physicians stated an increase in their reporting practice.     

Intra-articular Chlamydial Antigen and Inflammatory Arthritis

Joint material from 133 patients with well-characterized inflammatoryarthritis, including individuals likely to have suffered reactivearthiritis, was studied. The majority of patients were alsoexamined for the presence of genital tract infection with Chlamydiatrachomatis. Fluorescein-conjugated monoclonal antibodies demonstratedthe presence of C. trachomatis antigen in synovial fluid celldeposits or synovial sections from inflamed knee joints of sevenpatients with reactive arthritis. The significance of thesefindings is discussed, as is the low rate of detection of chlamydialantigen in either the genital tract or the joint from patientsin this study. We emphasize the need for further work aimedat identifying the relevant immunogenic chlamydial antigensresponsible for the initiation of reactive arthritis.     

Haemodynamic Studies During the Management of Severe Tetanus

Detailed invasive haemodynamic studies were performed in 27of 32 patients with severe tetanus. Nineteen had severe uncomplicatedtetanus and eight had associated major complications, chieflyinfection and pulmonary complications. The results were comparedwith those obtained from 15 healthy male volunteers who servedas controls. There were two deaths in 32 patients (mortality6.25 per cent). Severe tetanus without major complications wascharacterized by a high output hyperkinetic circulatory statewith tachycardia (heart rate 131 (19.2) beats/minute), increasedstroke volume index (43.1 (10.7) ml/m²), increased cardiac index(5.48 (0.94)1/min/m²) and a normal left ventricular stroke workindex (60.5 (15.9) g/m/m²). Volume loading demonstrated a significanthaemodynamic response and increased vascular capacitance. Evenso the maximum percent rise from baseline values of these indicesafter volume load was significantly higher in controls (p <0.001). Autonomic cardiovascular disturbances affected bothsympathetic and parasympathetic activity. Hypertension and tachycardiaalternating with hypotension and bradycardia were related tosudden fluctuations in systemic vascular resistance. Our studiessuggested some degree of myocardial dysfunction in patientswith severe uncomplicated tetanus. The haemodynamics of severetetanus were masked and altered by complicating infection, pneumonia,and atelectasis.     

Detection of antibodies to Trypanosoma cruzi among blood donors in the southwestern and western United States. II. Evaluation of a supplemental enzyme immunoassay and radioimmunoprecipitation assay for confirmation of seroreactivity

BACKGROUND: Chagas' disease, caused by the protozoan parasite Trypanosoma cruzi, is endemic to Latin America and may be transmitted in the United States via blood donated by infected immigrants. Blood- borne pathogens such as T. cruzi require supplemental testing for confirmation of seroreactivity. STUDY DESIGN AND METHODS: A study was undertaken to determine an optimal scheme for confirmation of seroreactivity in repeatedly reactive samples identified by the Chagas antibody enzyme immunoassay (EIA). The procedure for initial confirmation involves three purified antigens coated onto three separate polystyrene beads and uses an EIA format. If the sample is reactive with two of three or three of three antigens, it is confirmed as seroreactive. If none or one of three beads is reactive, the sample is indeterminate and subjected to a radioimmunoprecipitation assay (RIPA). The RIPA must demonstrate characteristic bands at 32, 34, and 90 kDa. RESULTS: When tested with sera from persons with potentially cross-reactive diseases (n = 39) or against a presumed negative population from southeast Wisconsin (n = 289), the confirmatory EIA had a specificity of 100 percent. Sensitivity was 100 percent (28/28) with xenodiagnosis-positive sera and 97.6 percent (80/82) with chagasic sera from Latin America. The RIPA showed a specificity of 100 percent in EIA- nonreactive samples (n = 100) and a sensitivity of 100 percent with both xenodiagnosis-positive (28/28) and chagasic (82/82) sera. CONCLUSION: The confirmatory EIA and the RIPA together provide a highly specific and sensitive means of confirming seroreactivity for antibodies to T. cruzi.     

Lymphome non hodgkinien Ki-1 positif révélé par des ulcérations cutanéomuqueuses et une glomérulonéphrite

Malignant lymphoma particularly of T phenotype can be associated with specific or non specific cutaneous lesions. These cutaneous manifestations can occur at the onset of the disease being sometimes the revealing sign or they can appear during the course of the lymphoreticular malignancies. Glomerulonephritis was also described in lymphoma. Ki- positive large cell lymphoma was recently identified. A new case is reported with lymphadenopathy and intestinal localisation revealed by cutaneous and mucosal ulcerations principally in the mouth and a focal segmental glomerulonephritis with endo- and extracapillary proliferation. The absence of lymphoma in cutaneous and renal lesions and the clinical presentation support the hypothesis of paraneoplastic manifestations, may be related to a vasculitis.     

Interventional cardiology live case presentations: Regulatory considerations

Live case presentations are increasingly common at interventional cardiology conferences. Taking advantage of significant advances in communication technology, broadcasts of procedures can be viewed as an extension of traditional medical education targeted to large groups of practitioners. However, there are important ethical, commercial, and patient safety issues associated with live cases that deserve attention. Use of investigational devices in live case demonstrations is subject to review and approval by FDA's Center for Devices and Radiological Health (CDRH), and the outcomes of patients participating in live cases are considered in the overall clinical study results. This article discusses CDRH's regulatory view of live case presentations with a focus on patient safety, clinical trial integrity, and concerns regarding improper medical device promotion. © 2010 Wiley‐Liss, Inc.     

Magnetic Resonance Imaging Volume of the Angular Gyri Predicts Financial Skill Deficits in People with Amnestic Mild Cognitive Impairment

OBJECTIVES: To better understand how brain atrophy in amnestic mild cognitive impairment (MCI) as measured using magnetic resonance imaging (MRI) volumetrics could affect instrumental activities of daily living (IADLs) such as financial abilities. DESIGN: Controlled, matched‐sample, cross‐sectional analysis regressing MRI volumetrics with financial performance measures. SETTING: University medical and research center. PARTICIPANTS: Thirty‐eight people with MCI and 28 older adult controls. MEASUREMENTS: MRI volumetric measurement of the hippocampi, angular gyri, precunei, and medial frontal lobes. Participants also completed neuropsychological tests and the Financial Capacity Instrument (FCI). RESULTS: Correlations were performed between FCI scores and MRI volumes in the group with MCI. People with MCI performed significantly below controls on the FCI and had significantly smaller hippocampi. Among people with MCI, performance on the FCI was moderately correlated with angular gyri and precunei volumes. Regression models demonstrated that angular gyrus volumes were predictive of FCI scores. Tests of mediation showed that measures of arithmetic and possibly attention partially mediated the relationship between angular gyrus volume and FCI score. CONCLUSION: Impaired financial abilities in amnestic MCI correspond with volume of the angular gyri as mediated by arithmetic knowledge. The findings suggest that early neuropathology within the lateral parietal region in MCI leads to a breakdown of cognitive abilities that affect everyday financial skills. The findings have implications for diagnosis and clinical care of people with MCI and AD.     

Statins and fenofibrate affect skeletal muscle chloride conductance in rats by differently impairing ClC-1 channel regulation and expression

Background and purpose:

Statins and fibrates can produce mild to life-threatening skeletal muscle damage. Resting chloride channel conductance (gCl), carried by the ClC-1 channel, is reduced in muscles of rats chronically treated with fluvastatin, atorvastatin or fenofibrate, along with increased resting cytosolic calcium in statin-treated rats. A high gCl, controlled by the Ca²⁺-dependent protein kinase C (PKC), maintains sarcolemma electrical stability and its reduction alters muscle function. Here, we investigated how statins and fenofibrate impaired gCl.

Experimental approach:

In rats treated with fluvastatin, atorvastatin or fenofibrate, we examined the involvement of PKC in gCl reduction by the two intracellular microelectrodes technique and ClC-1 mRNA level by quantitative real time-polymerase chain reaction. Direct drug effects were tested by patch clamp analysis on human ClC-1 channels expressed in human embryonic kidney (HEK) 293 cells.

Key results:

Chelerythrine, a PKC inhibitor, applied in vitro on muscle dissected from atorvastatin-treated rats fully restored gCl, suggesting the involvement of this enzyme in statin action. Chelerythrine partially restored gCl in muscles from fluvastatin-treated rats but not in those from fenofibrate-treated rats, implying additional mechanisms for gCl impairment. Accordingly, a decrease of ClC-1 channel mRNA was found in both fluvastatin-and fenofibrate-treated rat muscles. Fenofibric acid, the in vivo metabolite of fenofibrate, but not fluvastatin, rapidly reduced chloride currents in HEK 293 cells.

Conclusions and implications:

Our data suggest multiple mechanisms underlie the effect of statins and fenofibrate on ClC-1 channel conductance. While statins promote Ca²⁺-mediated PKC activation, fenofibrate directly inhibits ClC-1 channels and both fluvastatin and fenofibrate impair expression of mRNA for ClC-1.