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Increasingly, therapists and researchers have focused attention on domestic violence in lesbian relationships. To date, however, most research has described the incidence and types of physical violence and abuse. The present study sought to explore predictors of domestic violence in lesbian relationships. Lesbian participants filled out a survey measuring physical violence and physical aggression as well as relational and personality variables. Results indicated that lesbians do report some degree of domestic violence, characterized more often by physical aggression than by physical violence. Physical aggression was best predicted by fusion, followed by self-esteem and independence. For physical violence, however, control was the most important predictor, followed by independence, self-esteem and fusion. Implications and directions for future research are discussed. [ABSTRACT FROM AUTHOR]

Background and Objectives: Intraperitoneal chemotherapy can be administered as a single dose associated with hyperthermia (HIPEC) or in successive doses under normothermic conditions, such as early postoperative intraperitoneal chemotherapy (EPIC) or normothermic intraperitoneal chemotherapy (NIPEC or NIPEC-LT). Repetitive administration of intraperitoneal chemotherapy over a prolonged period may be associated with catheter-related complications, which are the primary cause of treatment interruption. This study aims to introduce and evaluate an innovative catheter system designed to mitigate these issues., Methods: Using a porcine experimental model, we tested a new catheter for long-term intraperitoneal access. Sixteen animals underwent catheter implantation followed by normothermic recirculation of peritoneal dialysis solution. Catheter functionality and any complications were monitored throughout successive treatment cycles., Results: The new catheter system demonstrated optimal recirculation and maintained its functionality throughout successive treatments, without complications. Catheter replacement with a guidewire was successful, ensuring continued efficacy., Conclusions: The innovative catheter system shows promise in reducing complications and improving compliance in successive intraperitoneal chemotherapy doses, justifying further clinical trials to confirm its efficacy in patients., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Introduction: Early in COVID-19, continuing professional development (CPD) providers quickly made decisions about program content, design, funding and technology. Although experiences during an earlier pandemic cautioned providers to make disaster plans, CPD was not entirely prepared for this event. We sought to better understand how CPD organisations make decisions about CPD strategy and operations during a crisis., Methods: This is a descriptive qualitative research study of decision making in two organisations: CPD at the University of Toronto (UofT) and the US-based Society for Academic Continuing Medical Education (SACME). In March 2021, using purposive and snowball sampling, we invited faculty and staff who held leadership positions to participate in semi-structured interviews. The interview focused on the individual's role and organisation, their decision-making process and reflections on how their units had changed because of COVID-19. Transcripts were reviewed, coded and analysed using thematic analysis. We used Mazmanian et al.'s Ecological Framework as a further conceptual tool., Results: We conducted eight interviews from UofT and five from SACME. We identified that decision making during the pandemic occurred over four phases of reactions and impact from COVID-19, including shutdown, pivot, transition and the 'new reality'. The decision-making ability of CPD organisations changed throughout the pandemic, ranging from having little or no independent decision-making ability early on to having considerable control over choosing appropriate pathways forward. Decision making was strongly influenced by the creativity, adaptability and flexibility of the CPD community and the need for social connection., Conclusions: This adds to literature on the changes CPD organisations faced due to COVID-19, emphasising CPD organisations' adaptability in making decisions. Applying the Ecological Framework further demonstrates the importance of time to decision-making processes and the relational aspect of CPD. To face future crises, CPD will need to embrace creative, flexible and socially connected solutions. Future scholarship could explore an organisation's ability to rapidly adapt to better prepare for future crises., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Purpose: Unprofessional behavior, which can include failure to engage, dishonest and/or disrespectful behavior, and poor self-awareness, can be demonstrated by medical trainees and practicing physicians. In the authors' experience, these types of behaviors are associated with exposure to adverse childhood experiences (ACEs). Given this overlap, the authors studied the percentage of ACEs among trainees and physicians referred for fitness-for-duty evaluations and patterns between the types of ACEs experienced and the reason for referral., Method: A final sample of 123 cases of U.S. trainees and physicians who had been referred to a Midwestern center for assessment and/or remediation of professionalism issues from 2013 to 2018 was created. Included professionalism lapses fell within 3 categories: boundary violation, disruptive behavior, or potential substance use disorder concerns. All participants completed a psychosocial developmental interview, which includes questions about ACE exposure. Overall rate of reported ACEs and types of ACEs reported were explored., Results: Eighty-six (70%) participants reported at least 1 ACE, while 27 (22%) reported 4 or more. Compared with national data, these results show significantly higher occurrence rates of 1 or more ACEs and a lower occurrence rate of 0 ACEs. ACEs that predicted reasons for referral were physical or sexual abuse, feeling unwanted or unloved, witnessing abuse of their mother or stepmother, or caretaker substance use., Conclusions: In this sample, ACE exposure was associated with professionalism issues. Remediating individuals with professionalism issues and exposure to ACEs can be complicated by heightened responses to stressful stimuli, difficulties with collaboration and trust, and decreased self-efficacy. Adoption of a trauma-informed medical education approach may help those that have been impacted by trauma rebuild a sense of control and empowerment. The findings of this study may be useful predictors in identifying those at risk of problematic behavior and recidivism before a sentinel event., (Copyright © 2021 by the Association of American Medical Colleges.)

Purpose: This paper presents the phenomenon of stigmatisation among injured immigrant and ethnocultural minority workers experiencing a long-standing disability. Stigmatisation was one of the main findings of our study, the aim of which was to gain insight into the work rehabilitation process in the context of intercultural relations in Quebec. Various categories of stakeholders took part in the study, which sought to describe their experiences and perspectives and to identify the constraints, barriers, facilitators, and specific needs they encounter in terms of intercultural competencies. Methods: A purposive sample of 40 individuals was selected and divided into four groups: workers ( N  = 9), clinicians ( N  = 15), workers' compensation board rehabilitation experts ( N  = 14), and workplace representatives ( N  = 2). Semi-structured interviews were conducted using the critical incident technique, combined with an "explicitation" interviewing technique. Data collection and analysis procedures were based on grounded theory. Results: This study shows that immigrant and ethnocultural minority workers may experience stigmatisation as a cumulative process involving different concomitant parts of their "identity": age, gender, social class, ethnicity, mental health, and occupational injuries. Cumulative stigma may aggravate personal distress and feelings of shame, rejection, and disqualification from full social acceptance. Negative anticipatory judgements made by practitioners may undermine the therapeutic relationship and breach mutual trust and confidence. Conclusions: The phenomenon of stigmatisation is well documented in the sociological and health literature, but studies tend to focus on only one type of stigma at a time. Future research should focus on the cumulative process of stigmatisation specifically affecting immigrant and ethnocultural minority workers and its potentially damaging impact on self-concept, healthcare delivery, rehabilitation interventions, and the return to work.Implications for rehabilitationThe repetition of certain clinical situations with people from certain groups should not lead practitioners to undue generalizations, even if they may sometimes be accurate; these generalizations must always be verified on a case by case basis.Ethnicity and culture, along with other social attributions, should serve as working hypotheses or support tools in health communication, not as hindrances to clinical reasoning.Practitioners should deepen their understanding of the patient's treatment expectations and the support available for rehabilitation in his family and community.Stigma in the context of care is linked to the idea of conforming to the proposed institutional models of care (including expected beliefs, attitudes, and behaviours). Therefore, practitioners should be aware that alleged differences, misunderstanding or disagreements can highlight an asymmetry in practitioner-patient power relationships.Organisations should also promote exchange and reflection on how to adapt their institutional models to avoid asymmetrical power relations.Intercultural training should be promoted at the various organisational levels so that managers, decision-makers, and practitioners share a common knowledge of the challenges of intervention in multi-ethnic settings.

Background: The literature on unprofessional behavior is reviewed. It is well accepted that unprofessional behavior, including a lack of civility and respect, can have a negative impact on patient safety and quality of care., Methods: We used a focused review in the context of 20 years of experience of assessing, treating, and remediating unprofessional behavior. The review highlights that unprofessional behavior can stem from a variety of sources, including health, psychological/psychiatric issues, social functioning or support, or a combination of these. The review covers the challenges in the work environment and the relationship between outcome, as experienced by the physician, and the likelihood the physician will repeat or modify his or her behavior., Results: Based on the evidence provided in the review and our clinical and research experience, we offer a new framework for the assessment, treatment, and remediation of physicians with professionalism transgressions: the Environmentally Valid Learning Approach. The approach is related to and expands on Miller's Pyramid by adding bio-psycho-social functioning and professional identity to the Pyramid. It emphasizes the dynamic and environmental characteristics of professional identity., Conclusions: Effective intervention is possible. Consideration of contributory factors, addressing/treating those factors, teaching/remediating skill deficiencies, and determining elements that need to be in place to foster implementation and maintenance of the developing skills are necessary components for successful resolution. The behavior is fully remediated when a self-sustaining alternative to the unprofessional behavior is established and the desired behavior becomes a permanent part of the physician's behavioral repertoire., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

California's building energy codes (Title 24, Part 6), updated triennially since 1978, are the most stringent in the nation. The aim of California contemporary energy policy in general, and the state's building codes and standards in particular, is the reduction of greenhouse gas emissions. The state has identified residential designs that "bring value to the grid" as a key constituent of this effort. This research quantifies the marginal costs that code requirements add to new residential construction, the quantity of carbon emissions and abatement expected at a statewide level, and the marginal abatement cost of homes built under the new 2019 standards relative to those built under the prior code. We model hourly energy consumption and emissions (2020-2050) for seven residential building types representative of California production housing for each of California's 16 climate zones. Costs and benefits of each housing type are analyzed under a 30-year timeframe. Our results indicate that the 2019 code allows for a wide range of emission profiles, including very high long-term emissions resulting from the use of natural gas and under high leak rates. The significant and previously unreported impact of pre-meter natural gas leaks emphasizes the challenges that natural gas creates with respect to meeting California's long-term GHG reduction goals. Marginal abatement costs are dependent on natural gas leak rates, but consistently indicate that all-electric homes represent the first-best policy option for residential sector GHG abatement in California.

This Invited Commentary highlights the prevalence of adverse childhood experiences and the potential effect that such experiences can have in the medical education setting on trainees, colleagues, and faculty. The author draws on 20 years of experience working in organizations devoted to helping physicians with disruptive behavior learn new behavioral skills to enable them to function within the complex medical environment. A case example-an amalgam of individuals who have presented for remediation-is used to illustrate the issues that result from adverse childhood experiences. There is a broad and well-understood literature demonstrating a correlation between early life trauma and medical and mental health issues. Adverse early life experiences can also contribute to attachment-related difficulties including problems with boundaries, trust, and suspiciousness; lack of reciprocity; lack of attunement with others' emotional states; as well as regulation issues, including difficulties labeling and expressing feelings and internal states. Difficulties with self-concept, including a lack of continuous and predictable sense of self, low self-esteem, and shame and guilt, are also associated with exposure to adverse childhood experiences. Given the documented high proportion of health care workers, including physicians, who are trauma survivors, trauma-sensitive education must be a priority, not only in medical school but across the educational continuum.

Competing Interests: The authors have declared that no competing interests exist.

Objectives: This study aims to characterize the relationships between the quality of the information given by the physician, the involvement of the patient in shared decision making (SDM), and outcomes in terms of satisfaction and anxiety pertaining to the treatment of inflammatory bowel disease (IBD)., Methods: A Web survey was conducted among 200 Canadian patients affected with IBD. The theoretical model of SDM was adjusted using path analysis. SAS software was used for all statistical analyses., Results: The quality of the knowledge transfer between the physician and the patient is significantly associated with the components of SDM: information comprehension, patient involvement and decision certainty about the chosen treatment. In return, patient involvement in SDM is significantly associated with higher satisfaction and, as a result, lower anxiety as regards treatment selection., Conclusions: This study demonstrates the importance of involving patients in shared treatment decision making in the context of IBD., Practice Implications: Understanding shared decision making may motivate patients to be more active in understanding the relevant information for treatment selection, as it is related to their level of satisfaction, anxiety and adherence to treatment. This relationship should encourage physicians to promote shared decision making., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To determine whether population-specific normative data should be employed when screening neurocognitive functioning as part of physician fitness for duty evaluations. If so, to provide such norms based on the evidence currently available., Methods: A comparison of published data from four sources was analyzed. Data from the two physician samples were then entered into a meta-analysis to obtain full information estimates and generate provisional norms for physicians., Results: Two-way analysis of variance (Study x Index) revealed a significant main effect and an interaction. Results indicate differences in mean levels of performance and standard deviation for physicians., Conclusions: Reliance on general population normative data results in under-identification of potential neuropsychological difficulties. Population specific normative data are needed to effectively evaluate practicing physicians.

Introduction: Continuous professional development relies on the link between performance and an educational process aimed at improving knowledge and skill. One of the most broadly used frameworks for assessing skills is Miller's Pyramid. This Pyramid has a series of levels of achievement beginning with knowledge (at the base) and ending with routine application in the clinical setting., Methods: The purpose of this study was to determine the degree of convergence of two measurement methods, one based on Miller's framework, the second using the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties (ACGME/ABMS) Core Competency framework. The data were gathered from the faculty of a large, Midwestern regional health care provider and hospital system. Data from 264 respondents were studied. The 360° data were from raters of physicians holding supervisory roles in the organization. The scale items were taken from an instrument that has been validated for both structure and known group prediction., Results: The Miller scale was purposely built for this application. The questions were designed to describe each level of the model. The Miller scale was reduced to a single dimension. This result was then regressed on the items from the 360° item ratings. Results of a multivariate analysis of variance isolated a significant relationship between the Miller's Pyramid score and the competency items (P < 0.001)., Discussion: These findings demonstrate a relationship between measures based on Miller's framework and behavioral measures based on the ABMS/ACGME core competencies. Equally important is the finding that while they are related they are not identical. These findings have implications for continuous professional development programing design.

Objective: Age correlated changes in mental and physical capacity have contributed to increasing concerns about older physicians' clinical competence. This paper explores the relationship between age and health in a clinical population referred for fitness for duty evaluations., Methods: Fifty cases from an evaluation center performing fitness for duty evaluations were randomly selected. Cases were reviewed for referral reason, demographic information, diagnosis, and recommendations., Results: Age ranged from 28-70 (median age of 51, mode of 45).Eighty-eight percent of cases had a diagnosed medical condition with potential cognitive sequellae., Conclusion: While the literature supports performance concerns in aging practitioners, health independent of age, appears to be an important contributing factor. A screening process considering biopsychosocial reserve and professional load while applicable to older clinicians would optimally be implemented for physicians across their careerspan., (© The Royal Australian and New Zealand College of Psychiatrists 2016.)

Background: Common single nucleotide polymorphisms at chromosome 4q25 (rs2200733, rs10033464) are associated with both lone and typical atrial fibrillation (AF). Risk alleles at 4q25 have recently been shown to predict recurrence of AF after ablation in a population of predominately lone AF, but lone AF represents only 5%-30% of AF cases., Objective: To test the hypothesis that 4q25 AF risk alleles can predict response to AF ablation in the majority of AF cases., Methods: Patients enrolled in the Vanderbilt AF Registry underwent 378 catheter-based AF ablations (median age 60 years; 71% men; 89% typical AF) between 2004 and 2011. The primary end point was time to recurrence of any nonsinus atrial tachyarrhythmia (atrial tachycardia, atrial flutter, or AF)., Results: Two-hundred atrial tachycardia, atrial flutter, or AF recurrences (53%) were observed. In multivariable analysis, the rs2200733 risk allele predicted a 24% shorter recurrence-free time (survival time ratio 0.76; 95% confidence interval [CI] 0.6-0.95; P = .016) compared with wild type. The heterozygous haplotype demonstrated a 21% shorter recurrence-free time (survival time ratio 0.79; 95% CI 0.62-0.99) and the homozygous risk allele carriers a 39% shorter recurrence-free time (survival time ratio 0.61; 95% CI 0.37-1.0; P = .037)., Conclusions: Risk alleles at the 4q25 loci predict impaired clinical response to AF ablation in a population of patients with predominately typical AF. Our findings suggest that the rs2200733 polymorphism may hold promise as an objectively measured patient characteristic that can be used as a clinical tool for selecting patients for AF ablation., (Copyright © 2013 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Obese patients with atrial fibrillation (AF) are frequently treated with AF ablation. We sought to examine whether a body mass index (BMI) threshold exists beyond which the odds of experiencing a complication from AF ablation increases. All patients enrolled in the Vanderbilt AF Registry who underwent catheter-based AF ablation from May 1999 to February 2012 were included. Major complications were recorded. Morbid obesity was defined as a BMI >40 kg/m(2) and examined in multivariable analysis. A total of 35 complications (6.8%) occurred in 512 ablations. Morbidly obese patients experienced a greater rate of complications (6 of 42, 14.3%) than the nonmorbidly obese (29 of 470, 6.2%; p = 0.046). Using a discrete BMI cutoff, the odds of complications increased 3.1-fold in those with morbid obesity (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.1 to 8.4, p = 0.03) and 2.1-fold for female gender (OR 2.1, 95% CI 1.04 to 4.38, p = 0.04). With BMI as a continuous variable, the odds of complications increased by 5% per 1 unit increase in BMI (OR 1.05, 95% CI 1.0 to 1.11, p = 0.05), and the increase for female gender was 2.2-fold (OR 2.2, 95% CI 1.1 to 4.6, p = 0.03). In conclusion, morbid obesity represents a BMI threshold above which the odds of complications with AF ablation increase significantly. The increase in complications appears to be driven primarily by events in women, suggesting that morbidly obese women are a special population when considering AF ablation., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Because U.S. restaurants are inspected at least annually against criteria in the U.S. Food and Drug Administration Model Food Code, large amounts of data are generated and should be systematically reviewed. The purpose of this study was to determine the relationships among the data obtained through health department inspections, the contributing factors to foodborne illness identified by the Centers for Disease Control and Prevention, and the risks of outbreaks of norovirus, Salmonella, and Clostridium perfringens infection associated with a specific restaurant. These agents were chosen for the analysis because they cause the majority of foodborne illnesses. A theoretical predictive assessment tool was built that extracts data from routine health department inspection reports for specific restaurants to establish a risk profile for each restaurant and identify the likelihood of a norovirus, Salmonella, or C. perfringens outbreak at that restaurant. The tool was used to examine inspection reports from restaurants known to have had confirmed norovirus, Salmonella, and C. perfringens outbreaks. Although evaluation of an extensive data set revealed lack of an overall association between outbreak inspection scores and routine inspection scores obtained at outbreak restaurant locations, certain specific violations were significantly more likely to be recorded. Significant differences in types of violations recorded during outbreak and routine inspections were determined. When risks based on violation type can be identified, targeted actions may be able to be prioritized and implemented to help decrease illnesses.

Millions of routine restaurant inspections are performed each year in the United States, and the Centers for Disease Control and Prevention has reported that a majority of foodborne illness outbreaks occur in restaurant settings. In an attempt to relate the data collected during inspections in Minnesota to illness likelihood, data from routine inspections conducted at outbreak restaurants were compared with data from routine inspections conducted at nonoutbreak restaurants. The goal was to identify differences in recorded violations. Significantly more violations were recorded at restaurants that had outbreaks. The majority of these violations were related to contamination in the facility and environment and to food handling procedures. Relative risks also were calculated for violations significantly more likely to occur at locations that had outbreaks of norovirus infection, Clostridium perfringens infection or toxin-type illness, and Salmonella infection. These three pathogens are estimated to cause the majority of foodborne illnesses in the United States. Meta-analysis of composited data for the three pathogens revealed 11 violations significantly more likely (α < 0.05) to be identified during routine inspections at outbreak restaurants than during inspections at nonoutbreak restaurants. Application of this information permits assessment of health department inspection data in a consistent fashion. This approach can help identify criteria more likely to be associated with outbreak locations and allow operators to focus on interventions that will have the most significant impact in higher risk establishments.

High accountability men in the medical, legal, corporate, and mental health professions sometimes engage in behavior that violates their fiduciary responsibilities. These highly skilled men may engage in disruptive or explosive behavior, cross sexual boundaries with clients or patients, abuse substances, or have other psychiatric problems that compromise their workplace performance. When this occurs, licensing boards, professional societies, or supervising executives often require the dysregulated man to seek assistance. This article reports on ways the Professional Renewal Center incorporates recommendations from "Gender Aware Therapy" in developing a male-friendly approach to conducting comprehensive multidisciplinary psychological assessments, and to providing intensive, multimodal, weeks-long treatment services., ((PsycINFO Database Record (c) 2010 APA, all rights reserved).)

Mixed lineage kinases (MLKs) function as Jun-N-terminal kinase (JNK) kinase kinases to transduce extracellular signals during development and homeostasis in adults. slipper (slpr), which encodes the Drosophila homolog of mammalian MLKs, has previously been implicated in activation of the JNK pathway during embryonic dorsal epidermal closure. To further define the specific functions of SLPR, we analyzed the phenotypic consequences of slpr loss and gain of function throughout development, using a semiviable maternal-effect allele and wild-type or dominant-negative transgenes. From these analyses we confirm that failure of dorsal closure is the null phenotype in slpr germline clones. In addition, there is a functional maternal contribution, which can suffice for embryogenesis in the zygotic null mutant, but rarely suffices for pupal metamorphosis, revealing later functions for slpr as the maternal contribution is depleted. Zygotic null mutants that eclose as adults display an array of morphological defects, many of which are shared by hep mutant animals, deficient in the JNK kinase (JNKK/MKK7) substrate for SLPR, suggesting that the defects observed in slpr mutants primarily reflect loss of hep-dependent JNK activation. Consistent with this, the maternal slpr contribution is sensitive to the dosage of positive and negative JNK pathway regulators, which attenuate or potentiate SLPR-dependent signaling in development. Although SLPR and TAK1, another JNKKK family member, are differentially used in dorsal closure and TNF/Eiger-stimulated apoptosis, respectively, a Tak1 mutant shows dominant genetic interactions with slpr, suggesting potential redundant or combinatorial functions. Finally, we demonstrate that SLPR overexpression can induce ectopic JNK signaling and that the SLPR protein is enriched at the epithelial cell cortex.

Objective: To evaluate safety and efficacy of longterm etanercept treatment in patients with disease modifying antirheumatic drug (DMARD) refractory rheumatoid arthritis (RA)., Methods: Safety results are reported for 714 patients who received etanercept in one of 7 initial trials or a longterm extension. Efficacy results are reported for 581 patients who enrolled in the extension., Results: Of the 714 patients enrolled in the initial trials, 581 (81%) enrolled in the extension, and 388 (54%) patients are continuing to receive etanercept therapy. The longest individual treatment was 8.2 years, with 3139 total patient-years of etanercept exposure. Rates of serious adverse events (overall rate=14.8 events/100 patient-yrs), serious infections (overall rate=4.2 events/100 patient-yrs), cancer (overall rate=1.0 events/100 patient-yrs), and deaths (overall rate=0.7 events/100 patient-yrs) were stable each year, through 8 years of etanercept exposure. For 356 patients who completed 6 years of etanercept treatment, response rates were ACR20=73%, ACR50=52%, ACR70=27%, DAS28 CRP good response=52%, and DAS28 CRP remission=37% of patients. Similar responses occurred in 167 patients who completed Year 7. Doses of concomitant methotrexate or corticosteroids were reduced in many patients who maintained clinical responses., Conclusion: The safety profile of etanercept was consistent over time, with rates of adverse events similar to those reported for patients with RA in general. Durable clinical responses were observed in some patients for 7 years or more. The benefit-to-risk ratio for longterm etanercept treatment remains highly favorable.

Our objective was to evaluate physician response to an educational program to increase referral of potential organ or tissue donors in an emergency department (ED). This study was a nonrandomized, controlled, before-after intervention trial at a nonuniversity teaching hospital with 45,000 annual patient visits to the ED. Two one-hour educational sessions reviewed with EMP (but not CON) the physician's role in requesting donation, donor criteria, required-request legislation, and services available from organ procurement professionals. Rates of consideration for donation, discussion with family, consent for donation, recovery of tissues or organs for donation and completion of a donor request form were evaluated before and after the intervention by a blinded chart reviewer. Prior to the intervention, tissue recovery was 0% of EMP and 4% for CON. After intervention, the EMP rate increased to 48% (p < 0.001) but CON remained unchanged (5%, p = 1.0). Similar increases limited to the EMP group were seen for mentioning donation in the narrative chart (1% to 68%, p < 0.001), discussion with family (1% to 65%, p < 0.001), and consent for donation (0% to 32%, p < 0.001). The effect of the intervention was not sustained, with decreased rates of mentioning donation (p = 0.004) and discussion with family (p = 0.02) over six months. Physician education increases request for donation, consent for donation, and recovery of tissue. The duration of this effect is short-lived; repeated interventions may be necessary.

Evolution of a multidisciplinary pain clinic in a rehabilitation hospital is described. The assessment process was facilitated, particularly with respect to psychiatric and psychological evaluation, by the preliminary administration of two well established but simple self-administered questionnaire instruments, the Illness Behaviour Questionnaire (IBQ) and the Crown-Crisp Experiential Index (CCEI). The characteristics of our pain clinic population are described. They demonstrate questionnaire profiles which are typical of pain patients. Attention is drawn to the CCEI profile now shown in three studies of pain patients, predominance of the somatic anxiety (S) scale occurring in all. Correlations between the IBQ and CCEI showed, inter alia, that the S scale is a measure of somatisation in pain patients. This paper aims to describe the changes in the clinic since previously published descriptions, to note the characteristics of our patient on the questionnaire instruments and to comment on the value of these questionnaires in the assessment of psychiatric symptoms and somatisation in pain clinic patients.

Despite mandatory request legislation, the lack of available donor organs and tissues continues to limit transplant efforts. The potential contribution from emergency department (ED) patients remains undefined. We reviewed the charts of patients dying in our ED for organs and tissues potentially suitable for transplantation, age, cause of death, and physician documentation of donation inquiry. Of 155 charts reviewed, potential donors were identified for corneas (99), bones (61), heart valves (42), and kidneys (3). Of the 155 charts, 130 (84%) made no mention of donation, and of 37 charts containing a donor request form, 34 (92%) were incorrectly filled out or left blank. Four charts (2.6%) mentioned donation in the narrative section, two (1.3%) documented discussion with family, and one patient was referred to our Organ Procurement Organization, with recovery of one kidney and heart valves. We conclude that physicians rarely document consideration of donation for patients dying in the ED; the number of potential donors far exceeds the number referred or recovered. Future efforts should focus on methods to increase recognition and referral of organ and tissue donors from the ED.

Data from this retrospective study indicate that a positive two-color T and/or B cell flow cytometric crossmatch (FCXM) is predictive of early renal allograft loss (less than 2 months) in cadaveric kidney donor recipients who had a negative crossmatch by the antihuman globulin complement-dependent cytotoxicity technique. Among 90 cadaveric kidney donor recipients (67 primary, 23 regrafts), 14 (8 primary, 6 regrafts) lost their renal allografts within 2 months, and 10 of the 14 were FCXM positive and HLA sensitized. The remaining 76 allografts survived beyond 2 months, 12 of which were FCXM-positive. Thus, the FCXM sensitivity rate for detecting early graft loss was 71%, and the specificity rate was 84%. Cadaveric graft-loss rates at 2 months were 33% for primary and 60% for FCXM-positive regrafts in contrast to 7% for primary and 0% for FCXM-negative regrafts. The difference in early graft loss between FCXM-positive and FCXM-negative recipients was statistically significant (P less than 0.0001). Subset analyses of FCXM-positive graft recipients indicate: (1) previous early graft loss contraindicates transplantation of an FXCM-positive regraft (P = 0.03); and (2) panel reactive antibody (PRA) less than or equal to 10% at crossmatch is not associated with early graft loss (P = 0.04). There was no significant difference in 1-year graft survival between primary and regrafts in either FCXM-negative recipients (85% vs. 77%, respectively) or FCXM-positive recipients (67% vs. 40%). All 12 of the FCXM-positive primary and regrafts that survived 2 months continued to function at 2 years. Stepwise logistic regression analysis of 5 independent predictor variables (FCXM status, gender, primary vs. regraft status, PRA level, and HLA mismatched antigens) indicated that the FCXM test was the best predictor of early graft loss. When FCXM results of the 90 cadaveric graft recipients were ranked in three groups, an FCXM channel shift of 29 or greater (third tertile) on a 1024 channel log scale was associated with a 7.0-fold (95% confidence interval 1.9-25.5) increased risk of early graft failure when compared to the first two tertiles. These data indicate that the FCXM offers an additional approach for identifying sensitized patients at risk of early renal allograft loss.

Fifty patients with chronic low-back pain were subjected to extensive medical, psychiatric, and psychosocial assessment by a comprehensive Low Back Pain Clinic. Most patients were found to have easily identifiable environment factors which influenced the persistence of the symptomatology. All patients were significantly functionally impaired, and whilst neurologic findings were uncovered in only 12 patients, most had restricted movement of the lumbar spine. The initiating cause of the low-back pain was usually from a minor injury or no injury at all. Thirty-two patients were given psychiatric diagnoses, but only one patient was thought to warrant psychiatric treatment. Whilst some were considered to be candidates for limited further conservative treatment, only two were subjected to further surgery (one fusion, one posterior facet rhizotomy). Only nine were admitted to an inpatient behavior modification program, and the results of this effort were modest. The major benefit was seen to be the definitive diagnosis, prognosis, and medical and social planning which was given to all 50 patients upon conclusion of the assessment. The assessment proved to be of benefit to the patient, the referring doctor, the team itself, as well as all other interested parties, such as his family, insurance company, and lawyer.