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Purpose: To explore if cold debriefing, which by definition, occurs days to weeks following the critical event, addresses identified barriers to routine debriefing and results in instituting debriefing as standard practice in the perianesthesia division at the site hospital., Design: A qualitative descriptive design using case study reviews METHODS: Seven critical events, meeting the criteria of a preproject list, were debriefed by the patient's primary nurse using a cold debriefing method. Following the debriefing session, the nurse outlining the event, and the staff in attendance were asked to complete a short survey. Knowledge gained or education needed, suggestions for process improvements, and perceived safety of the environment, and feeling safe to provide feedback were assessed., Findings: Identified barriers were reduced with the institution of cold debriefing. An average of 33% of the working staff were able to attend at least one debriefing session, indicating the barrier of time may be diminished by using cold debriefing. Most staff and debriefers also felt the environment was safe, and feedback provided during the debriefing sessions resulted in identified needed education and process improvement measures., Conclusions: Implementation of cold debriefing to share and examine information following a critical event may address common barriers, result in process improvement measures, and identify educational needs required by the perianesthesia staff., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Background: We sought to evaluate changes in In-Training Examination (ITE) scores and associations with clinical work during the COVID-19 pandemic. We hypothesized that residents saw a decrease in clinical encounters during the pandemic and that this would be associated with smaller gains in ITE scores., Methods: We compared ITE score changes with data on patient notes for three classes of pediatric residents at four residency programs: one not exposed to the pandemic during their intern year who entered residency in 2018, one partially exposed to COVID-19 in March of their intern year (2019-2020), and one that was fully exposed to the pandemic, starting residency in June of 2020., Results: ITE scores on average improved from the PGY1 to PGY2 year in the "no covid" and "partial COVID" cohorts. The "full COVID" cohort had little to no improvement, on average. The total number of patient encounters was not associated with a change in ITE scores from PGY1 to PGY2. There was a small but statistically significant association between change in ITE score and number of inpatient H+P notes., Conclusions: A drop in ITE scores occurred in pediatric residents who entered residency during the COVID-19 pandemic. This change was largely unrelated to clinical encounter number changes., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest, competing interests, or corporate sponsors., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Pediatric cancer outcomes have significantly improved, and yet this success is not spread equally across cancer types or patients. Disparities data in pediatric oncology highlight needed improvements in access to care, including clinical trials and advanced testing for all patients. For cancers such as brain tumors and sarcomas, continued advancement in understanding the biology of tumor heterogeneity is an essential step toward finding new therapeutic combinations to improve outcomes. Pediatric cancer survivors need access to emerging technologies aimed at reducing or better managing toxicities from therapy. With advances in treatment and survival, pediatric oncology patients continue to need longitudinal, multidisciplinary subspecialty care. Refining the communication between pediatric oncologists, primary pediatricians, survivorship clinics, and adult primary care is key in ensuring the best lifelong care of pediatric cancer survivors. In this State-of-The-Art review, we discuss 5 major domains in pediatric oncology: reducing toxicity, cancer biology, novel therapies, detection and monitoring, and access to care, to highlight recent advances and areas for continued improvement.

Differential hypoxaemia (DH) is common in patients supported by femoral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and can cause cerebral hypoxaemia. To date, no models have studied the direct impact of flow on cerebral damage. We investigated the impact of V-A ECMO flow on brain injury in an ovine model of DH. After inducing severe cardiorespiratory failure and providing ECMO support, we randomised six sheep into two groups: low flow (LF) in which ECMO was set at 2.5 L min -1 ensuring that the brain was entirely perfused by the native heart and lungs, and high flow (HF) in which ECMO was set at 4.5 L min -1 ensuring that the brain was at least partially perfused by ECMO. We used invasive (oxygenation tension-PbTO 2 , and cerebral microdialysis) and non-invasive (near infrared spectroscopy-NIRS) neuromonitoring, and euthanised animals after five hours for histological analysis. Cerebral oxygenation was significantly improved in the HF group as shown by higher PbTO 2 levels (+ 215% vs - 58%, p = 0.043) and NIRS (67 ± 5% vs 49 ± 4%, p = 0.003). The HF group showed significantly less severe brain injury than the LF group in terms of neuronal shrinkage, congestion and perivascular oedema (p < 0.0001). Cerebral microdialysis values in the LF group all reached the pathological thresholds, even though no statistical difference was found between the two groups. Differential hypoxaemia can lead to cerebral damage after only a few hours and mandates a thorough neuromonitoring of patients. An increase in ECMO flow was an effective strategy to reduce such damages., (© 2023. The Author(s).)

In polycystic kidney disease (PKD), fluid-filled cysts arise from tubules in kidneys and other organs. Human kidney organoids can reconstitute PKD cystogenesis in a genetically specific way, but the mechanisms underlying cystogenesis remain elusive. Here we show that subjecting organoids to fluid shear stress in a PKD-on-a-chip microphysiological system promotes cyst expansion via an absorptive rather than a secretory pathway. A diffusive static condition partially substitutes for fluid flow, implicating volume and solute concentration as key mediators of this effect. Surprisingly, cyst-lining epithelia in organoids polarize outwards towards the media, arguing against a secretory mechanism. Rather, cyst formation is driven by glucose transport into lumens of outwards-facing epithelia, which can be blocked pharmacologically. In PKD mice, glucose is imported through cysts into the renal interstitium, which detaches from tubules to license expansion. Thus, absorption can mediate PKD cyst growth in human organoids, with implications for disease mechanism and potential for therapy development., (© 2022. The Author(s).)

New variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to arise and prolong the coronavirus disease 2019 (COVID-19) pandemic. Here, we used a cell-free expression workflow to rapidly screen and optimize constructs containing multiple computationally designed miniprotein inhibitors of SARS-CoV-2. We found the broadest efficacy was achieved with a homotrimeric version of the 75-residue angiotensin-converting enzyme 2 (ACE2) mimic AHB2 (TRI2-2) designed to geometrically match the trimeric spike architecture. Consistent with the design model, in the cryo-electron microscopy structure TRI2-2 forms a tripod at the apex of the spike protein that engaged all three receptor binding domains simultaneously. TRI2-2 neutralized Omicron (B.1.1.529), Delta (B.1.617.2), and all other variants tested with greater potency than the monoclonal antibodies used clinically for the treatment of COVID-19. TRI2-2 also conferred prophylactic and therapeutic protection against SARS-CoV-2 challenge when administered intranasally in mice. Designed miniprotein receptor mimics geometrically arrayed to match pathogen receptor binding sites could be a widely applicable antiviral therapeutic strategy with advantages over antibodies in greater resistance to viral escape and antigenic drift, and advantages over native receptor traps in lower chances of autoimmune responses.

Background: The influence of renin-angiotensin-aldosterone system (RAAS) inhibitors on the critically ill COVID-19 patients with pre-existing hypertension remains uncertain. This study examined the impact of previous use of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on the critically ill COVID-19 patients., Methods: Data from an international, prospective, observational cohort study involving 354 hospitals spanning 54 countries were included. A cohort of 737 COVID-19 patients with pre-existing hypertension admitted to intensive care units (ICUs) in 2020 were targeted. Multi-state survival analysis was performed to evaluate in-hospital mortality and hospital length of stay up to 90 days following ICU admission., Results: A total of 737 patients were included-538 (73%) with pre-existing hypertension had received ACEi/ARBs before ICU admission, while 199 (27%) had not. Cox proportional hazards model showed that previous ACEi/ARB use was associated with a decreased hazard of in-hospital death (HR, 0.74, 95% CI 0.58-0.94). Sensitivity analysis adjusted for propensity scores showed similar results for hazards of death. The average length of hospital stay was longer in ACEi/ARB group with 21.2 days (95% CI 19.7-22.8 days) in ICU and 6.7 days (5.9-7.6 days) in general ward compared to non-ACEi/ARB group with 16.2 days (14.1-18.6 days) and 6.4 days (5.1-7.9 days), respectively. When analysed separately, results for ACEi or ARB patient groups were similar for both death and discharge., Conclusions: In critically ill COVID-19 patients with comorbid hypertension, use of ACEi/ARBs prior to ICU admission was associated with a reduced risk of in-hospital mortality following adjustment for baseline characteristics although patients with ACEi/ARB showed longer length of hospital stay. Clinical trial registration The registration number: ACTRN12620000421932; The date of registration: 30, March 2020; The URL of the registration: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12620000421932 ., (© 2022. The Author(s).)

Kidneys are critical target organs of COVID-19, but susceptibility and responses to infection remain poorly understood. Here, we combine SARS-CoV-2 variants with genome-edited kidney organoids and clinical data to investigate tropism, mechanism, and therapeutics. SARS-CoV-2 specifically infects organoid proximal tubules among diverse cell types. Infections produce replicating virus, apoptosis, and disrupted cell morphology, features of which are revealed in the context of polycystic kidney disease. Cross-validation of gene expression patterns in organoids reflects proteomic signatures of COVID-19 in the urine of critically ill patients indicating interferon pathway upregulation. SARS-CoV-2 viral variants alpha, beta, gamma, kappa, and delta exhibit comparable levels of infection in organoids. Infection is ameliorated in ACE2-/- organoids and blocked via treatment with de novo-designed spike binder peptides. Collectively, these studies clarify the impact of kidney infection in COVID-19 as reflected in organoids and clinical populations, enabling assessment of viral fitness and emerging therapies.

Interferon (IFN) inhibits HIV replication by inducing antiviral effectors. To comprehensively identify IFN-induced HIV restriction factors, we assembled a CRISPR sgRNA library of Interferon Stimulated Genes (ISGs) into a modified lentiviral vector that allows for packaging of sgRNA-encoding genomes in trans into budding HIV-1 particles. We observed that knockout of Zinc Antiviral Protein (ZAP) improved the performance of the screen due to ZAP-mediated inhibition of the vector. A small panel of IFN-induced HIV restriction factors, including MxB, IFITM1, Tetherin/BST2 and TRIM5alpha together explain the inhibitory effects of IFN on the CXCR4-tropic HIV-1 strain, HIV-1 LAI , in THP-1 cells. A second screen with a CCR5-tropic primary strain, HIV-1 Q23.BG505 , described an overlapping, but non-identical, panel of restriction factors. Further, this screen also identifies HIV dependency factors. The ability of IFN-induced restriction factors to inhibit HIV strains to replicate in human cells suggests that these human restriction factors are incompletely antagonized., Editorial Note: This article has been through an editorial process in which the authors decide how to respond to the issues raised during peer review. The Reviewing Editor's assessment is that all the issues have been addressed (see decision letter)., Competing Interests: MO, LH, JV, FR, DH, RB, JD, JO, ME No competing interests declared, (© 2018, OhAinle et al.)

Background: Among the many modalities of error detection in academic pediatric hospitals, patient safety reporting is an important component, particularly for unexpected events. Residents recognize the importance of reporting but cite some barriers to doing so. A rubric was developed to guide resident reporting and streamline information gathering in patient safety reports. The rubric used the acronym SAFEST as a reminder to include 6 key elements:1. Staff involved in the incident.2. Actual event description.3. Follow-up initiated.4. Effect on patient.5. Standard of care described.6. To-do/suggestions for improvement., Objectives: This study was designed to determine if the addition of this educational rubric into a standard quality improvement curriculum improves the consistency of information documented in patient safety reports as a subset of a larger quality improvement project aimed at improving safety reporting., Methods: A team of faculty members analyzed individual resident error reports for adherence to the 6 tenets of the SAFEST mnemonic., Results: From April to October of 2014, 2015, and 2016, a convenience sample of 131, 110, and 132 reports, respectively, were extracted and analyzed. For the rates of reporting "staff involved" and "standard of care," the differences over time were significant, both with P values < 0.001. After training, residents were 2.2 times more likely to report on the "staff involved" in the error and 1.8 times more likely to report the "standard of care.", Discussion: These results describe successful education on a rubric designed to improve the content of patient safety reports.

Objectives: The purpose of this study was to measure changes in buccolingual inclination and in thickness of maxillary and mandibular buccal and lingual bone of maxillary and mandibular molars following orthodontic treatment using edgewise mechanics., Materials and Methods: Cone-beam computed tomography scans of 48 patients taken before and after completion of comprehensive orthodontic treatment were collected for this retrospective study. Buccolingual molar inclinations were reported as angular measurements using the long axis of the teeth and inferior border of the nasal floor and inferior border of the mandible, respectively. Distances between the buccal and lingual cusps of maxillary and mandibular molars, respectively, were measured to the occlusal plane to assess the change in buccolingual inclination after orthodontic treatment. The amount of buccal and lingual bone at the level of the root apex of each molar was also evaluated before and after orthodontic treatment., Results and Conclusion: Orthodontic edgewise mechanics caused significant increases in mandibular first molars' inclination angle, lingual bone, and mandibular second molars' buccal bone and inclination angle. Significant decreases were noted in mandibular first molars' buccal bone, inclination distance and mandibular second molars' lingual bone and inclination distance. Maxillary teeth had fewer significant changes than the mandibular teeth. Significant decreases were found for maxillary first molars' buccal bone, inclination distance, and maxillary second molar buccal bone., (Published by Elsevier Masson SAS.)

Many challenging engineering problems are regular, meaning solutions to one part of a problem can be reused to solve other parts. Evolutionary algorithms with indirect encoding perform better on regular problems because they reuse genomic information to create regular phenotypes. However, on problems that are mostly regular, but contain some irregularities, which describes most real-world problems, indirect encodings struggle to handle the irregularities, hurting performance. Direct encodings are better at producing irregular phenotypes, but cannot exploit regularity. An algorithm called HybrID combines the best of both: it first evolves with indirect encoding to exploit problem regularity, then switches to direct encoding to handle problem irregularity. While HybrID has been shown to outperform both indirect and direct encoding, its initial implementation required the manual specification of when to switch from indirect to direct encoding. In this paper, we test two new methods to improve HybrID by eliminating the need to manually specify this parameter. Auto-Switch-HybrID automatically switches from indirect to direct encoding when fitness stagnates. Offset-HybrID simultaneously evolves an indirect encoding with directly encoded offsets, eliminating the need to switch. We compare the original HybrID to these alternatives on three different problems with adjustable regularity. The results show that both Auto-Switch-HybrID and Offset-HybrID outperform the original HybrID on different types of problems, and thus offer more tools for researchers to solve challenging problems. The Offset-HybrID algorithm is particularly interesting because it suggests a path forward for automatically and simultaneously combining the best traits of indirect and direct encoding.

Context: New regulations were implemented in King County, Washington, in 2010 requiring pet businesses to obtain a permit from Public Health-Seattle & King County (Public Health) and undergo annual inspections to provide education and ensure compliance with regulatory standards. The regulations were developed as a tool for zoonotic disease control and prevention education for businesses and their customers, as well as for environmental protection., Objective: To assess the acceptance, benefits, and challenges of the new regulations and identify ways for Public Health to improve educational efforts and assist businesses with compliance., Design: Cross-sectional survey., Setting: King County, Washington., Participants: Pet businesses with Public Health permits in 2013., Main Outcome Measure: Self-administered survey responses., Results: The response rate was 40.5%. The majority of respondents provided grooming, pet day care, and kennel/boarding services from small, independent businesses. Sixty-one percent reported Public Health inspections as beneficial, especially concerning disinfection procedures and using an infection control plan. Almost three-fourths of respondents used the Public Health template to develop the infection control plan. Forty-four percent reported using the educational materials provided by Public Health, and 62% used educational materials from other sources. Most respondents reported that they gained benefits from the pet business permit, although fewer agreed that they obtained a good value from the permit and fee. The most common benefits reported were protection of animal and human health and establishing the credibility of the pet business., Conclusions: Major challenges with the implementation of the pet business regulations were not generally reported by respondents. Most respondents reported a collaborative relationship between Public Health and the pet businesses. Improvements in infection control practices and positive responses to the inspections were reported by pet businesses. Survey results were used to improve infection control plan templates, increase the use of educational materials, and improve the Web site and business portal performance.

Objective: To estimate outcomes and costs of surveillance strategies after treatment for high-grade cervical intraepithelial neoplasia (CIN)., Methods: A hypothetical cohort of women was evaluated after treatment for CIN 2 or 3 using a Markov model incorporating data from a large study of women treated for CIN, systematic reviews of test accuracy, and individual preferences. Surveillance strategies included initial conventional or liquid-based cytology, human papillomavirus testing, or colposcopy 6 months after treatment, followed by annual or triennial cytology. Estimated outcomes included CIN, cervical cancer, cervical cancer deaths, life expectancy, costs, cost per life-year, and cost per quality-adjusted life-year., Results: Conventional cytology at 6 and 12 months, followed by triennial cytology, was least costly. Compared with triennial cytology, annual cytology follow-up reduced expected cervical cancer deaths by 73% to 77% and had an average incremental cost per life-year gained of $69,000 to $81,000. For colposcopy followed by annual cytology, the incremental cost per life-year gained ranged from $70,000 to more than $1 million, depending on risk. Between-strategy differences in mean additional life expectancy per woman were less than 4 days; differences in mean incremental costs per woman were as high as $822. In the cost-utility analysis, colposcopy at 6 months followed by annual cytology had an incremental cost per quality-adjusted life-year of less than $5,500. Human papillomavirus testing or liquid-based cytology added little to no improvement to life-expectancy with higher costs., Conclusion: Annual conventional cytology surveillance reduced cervical cancers and cancer deaths compared with triennial cytology. For high risk of recurrence, a strategy of colposcopy at 6 months increased life expectancy and quality-adjusted life expectancy. Human papillomavirus testing and liquid-based cytology increased costs, but not effectiveness, compared with traditional approaches.

Objectives: Data are lacking on how women view alternative approaches to surveillance for cervical cancer after treatment of high-grade cervical intraepithelial neoplasia. We measured and compared patient preferences (utilities) for scenarios with varying surveillance strategies and outcomes to inform guidelines and cost-effectiveness analyses of post-treatment surveillance options., Methods: English- or Spanish-speaking women who had received an abnormal Pap test result within the past 2 years were recruited from general gynecology and colposcopy clinics and newspaper and online advertisements in 2007 and 2008. Participation consisted of one face-to-face interview, during which utilities for 11 different surveillance scenarios and their associated outcomes were elicited using the time tradeoff metric. A sociodemographic questionnaire also was administered., Results: 65 women agreed to participate and successfully completed the preference elicitation exercises. Mean utilities ranged from 0.989 (undergoing only a Pap test, receiving normal results) to 0.666 (invasive cervical cancer treated with radical hysterectomy or radiation and chemotherapy). Undergoing both Pap and HPV tests and receiving normal/negative results had a lower mean utility (0.953) then undergoing only a Pap test and receiving normal results (0.989). Having both tests and receiving normal Pap but positive HPV results was assigned an even lower mean utility (0.909). 15.9% of the respondents gave higher utility scores to the Pap plus HPV testing scenario (with normal/negative results) than to the "Pap test alone" scenario (with normal results), while 17.5% gave the Pap test alone scenario a higher utility score., Conclusions: Preferences for outcomes ending with normal results but involving alternative surveillance processes differ substantially. The observed differences in utilities have important implications for clinical guidelines and cost-effectiveness analyses., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: In cost-effectiveness analysis (CEA), the effects of health-care interventions on multiple health dimensions typically require consideration of both quantity and quality of life., Objectives: To explore the impact of alternative approaches to quality-of-life adjustment using patient preferences (utilities) on the outcome of a CEA on use of tamoxifen for breast cancer risk reduction., Research Design: A state transition Markov model tracked hypothetical cohorts of women who did or did not take 5 years of tamoxifen for breast cancer risk reduction. Incremental quality-adjusted effectiveness and cost-effectiveness ratios (ICERs) for models including and excluding a utility adjustment for menopausal symptoms were compared with each other and to a global utility model., Subjects: Two hundred fifty-five women aged 50 and over with estimated 5-year breast cancer risk >or=1.67% participated in utility assessment interviews., Measures: Standard gamble utilities were assessed for specified tamoxifen-related health outcomes, current health, and for a global assessment of possible outcomes of tamoxifen use., Results: Inclusion of a utility for menopausal symptoms in the outcome-specific models substantially increased the ICER; at the threshold 5-year breast cancer risk of 1.67%, tamoxifen was dominated. When a global utility for tamoxifen was used in place of outcome-specific utilities, tamoxifen was dominated under all circumstances., Conclusions: CEAs may be profoundly affected by the types of outcomes considered for quality-of-life adjustment and how these outcomes are grouped for utility assessment. Comparisons of ICERs across analyses must consider effects of different approaches to using utilities for quality-of-life adjustment.

Background: Tamoxifen is a prototypic cancer chemopreventive agent, yet clinical trials have not evaluated its effect on mortality or the impact of drug pricing on its cost-effectiveness., Methods: A state-transition Markov model for a hypothetical cohort of women age 50 years was used to evaluate the effects of tamoxifen on mortality and tamoxifen price on cost-effectiveness. Incidence and mortality rates for breast and endometrial cancers were derived from Surveillance, Epidemiology and End Results statistics, and noncancer outcomes were obtained from published studies. Relative risks of outcomes were derived from the National Surgical Adjuvant Breast and Bowel Project P-1 trial. Costs were based on Medicare reimbursements., Results: Projected overall mortality for women at 1.67% 5-year breast cancer risk showed little difference with or without tamoxifen, resulting in a cost-effectiveness ratio of $1,335,690 per life-year saved as a result of tamoxifen use. Adjusting for the differential impact of estrogen receptor-negative cancers, tamoxifen increased mortality for women with a uterus until the 5-year breast cancer risk reached > or =2.1%. Assigning the Canadian price for tamoxifen dramatically reduced the incremental cost (to $123,780 per life-year saved). At that price, the use of tamoxifen was less costly and more effective for women with 5-year breast cancer risks >4%., Conclusions: Tamoxifen may increase mortality in women at the lower end of the "high-risk" range for breast cancer. If prices in the U.S. approximated Canadian prices, then tamoxifen use for breast cancer risk reduction in women with a 5-year risk >3% could be a reasonable strategy to reduce the incidence of breast cancer. Because they are used by many unaffected individuals, the price of chemopreventive agents has a major influence on their cost-effectiveness.

Over the past decade, the courts have been called upon to apply the provisions of the Americans With Disabilities Act and Section 504 of the Rehabilitation Act in several cases with implications for programs of nursing education. Courts have restricted who may be considered a qualified individual with disabilities. They have clarified the relative obligations of both students and educators in determining accommodations. Courts have been especially deferential to educational programs preparing health care professionals when program standards and pedagogical requirements are clearly articulated. However, accessibility and compliance with recommendations for accommodations are required at all sites where students are educated. Less clear are judicial interpretations related to making technology accessible and to the disclosure by programs of information about students' disabilities during licensing. These findings lead to several conclusions. First is the need for development of profession-wide standards of competencies and skills for nurses. Second is the need for dialogue about the potential for disability discrimination between nursing educators and state licensing bodies. Last is that faculty and administrators can proceed with some degree of confidence in protecting program practices that are based on sound pedagogical reasoning.

Type 1 diabetes is a debilitating condition, affecting millions worldwide, that is characterized by the autoimmune destruction of insulin-producing pancreatic islets of Langerhans. Although exogenous insulin administration has traditionally been the mode of treatment for this disease, recent advancements in the transplantation of donor-derived insulin-producing cells have provided new hope for a cure. However, in order for islet transplantation to become a widely used technique, an alternative source of cells must be identified to supplement the limited supply currently available from cadaveric donor organs. Stem cells represent a promising solution to this problem, and current research is being aimed at the creation of islet-endocrine tissue from these undifferentiated cells. This review presents a summary of the research to date involving stem cells and cell replacement therapy for type 1 diabetes. The potential for the differentiation of embryonic stem (ES) cells to islet phenotype is discussed, as well as the possibility of identifying and exploiting a pancreatic progenitor/stem cell from the adult pancreas. The possibility of creating new islets from adult stem cells derived from other tissues, or directly form other terminally differentiated cell types is also addressed. Finally, a model for the isolation and maturation of islets from the neonatal porcine pancreas is discussed as evidence for the existence of an islet precursor cell in the pancreas.

The discovery of a pancreatic adult stem cell would have significant implications for cell-based replacement therapies for type 1 diabetes mellitus. Nestin, a marker for neural precursor cells, has been suggested as a possible marker for islet progenitor cells. We have characterized the expression and localization of nestin in both the intact human pancreas and clinical human pancreatic islet grafts. Nestin was found to be expressed at different levels in the acinar component of human pancreatic biopsies depending on donor, as well as in ductal structures and islets to some degree. In islets, insulin-producing beta-cells rarely co-expressed the protein, and in the ducts a small percentage (1-2%) of cells co-expressed nestin and cytokeratin 19 (CK19) while most expressed only CK19 (90%) or nestin (5-10%) alone. Assessment of nestin expression in neonatal pancreatic sections revealed an increased number of islet-associated positive cells as compared with adult islets. Nestin immunoreactivity was also found in cells of the pancreatic vasculature and mesenchyme as evidenced by co-localization with smooth muscle actin and vimentin. Samples from post-islet isolation clinical islet grafts revealed a pronounced heterogeneity in the proportion of nestin-positive cells (<1-72%). Co-localization studies in these grafts showed that nestin is not co-expressed in endocrine cells and rarely (<5%) with cytokeratin-positive ductal cells. However, relatively high levels of co-expression were found with acinar cells and cells expressing the mesenchymal marker vimentin. In conclusion we have shown a diffuse and variable expression of nestin in human pancreas that may be due to a number of different processes, including post-mortem tissue remodeling and cellular differentiation. For this reason nestin may not be a suitable marker solely for the identification of endocrine precursor cells in the pancreas.

Objectives: We examined the relationships among depressive symptoms, physician diagnosis of depression, and charges for care., Study Design: We used a prospective observational design., Population: Five hundred eight new adult patients were randomly assigned to senior residents in family practice and internal medicine., Outcomes Measured: Self-reports of health status assessment (Medical Outcomes Study Short Form-36) and depressive symptoms (Beck Depression Inventory) were determined at study entry and at 1-year follow-up. Physician diagnosis of depression was determined by chart audit; charges for care were monitored electronically., Results: Symptoms of depression and the diagnosis of depression were associated with charges for care. Statistical models were developed to identify predictors for the occurrence and magnitude of medical charges. Neither depressive symptoms nor diagnosis of depression significantly predicted the occurrence of charges in the areas studied, but physician diagnosis of depression predicted the magnitude of primary care and total charges., Conclusions: A complex relationship exists among depressive symptoms, the diagnosis of depression, and charges for medical care. Understanding these relationships may help primary care physicians diagnose depression and deliver primary care to depressed patients more effectively while managing health care expenditures.

An information revolution is occurring in home health care documentation processes and systems. The federally mandated Outcomes and Assessment Information Set (OASIS) for patient assessment and the use of electronic patient medical records will significantly affect the conduct of nursing research in home health care. The purposes of this article are to inform potential home care nurse researchers about the standardization of patient information as exemplified by OASIS and electronic patient medical records and recommend strategies to accommodate these changes. The potential for meaningful, scholarly studies in home care has never been greater, but researchers must address new challenges and adapt investigations accordingly.

The immunosuppressive activity of cyclosporine is mediated by inhibiting calcineurin phosphatase. However, calcineurin is widely distributed in other tissues. We examined the degree of calcineurin inhibition by cyclosporine in various tissues. In vitro, the cyclosporine concentration inhibiting 50% (IC50) of calcineurin was to approximately 10 ng/mL in human and mouse leukocytes suspensions. In vitro and in vivo IC50s of cyclosporine in homogenates of mouse kidney, heart, liver, testis, and spleen were also comparable (9-48 ng/mL). The maximum calcineurin inhibition by cyclosporine varied, from 83 to 95% of calcineurin activity in spleen, kidney, liver, and testis to 60% in heart and only 10% in brain. Maximum calcineurin inhibition was increased by the addition of cyclophilin A, indicating that cyclophilin concentrations were limiting in some tissues, at least in this assay. Western analysis of mouse tissues showed significantly less cyclophilin in heart than other tissues. cyclosporine concentrations per weight of tissue protein were highest in kidney and liver and lowest in brain and testis after oral dosing, with intermediate levels in spleen, heart, and whole blood. Thus each cyclosporine dose produces rapid and wide-spread inhibition of calcineurin in tissues, with differences in total susceptibility of each tissue.

Our purpose was to explore why women are more likely than men to be diagnosed as depressed by their primary care physician. Women were found to have more depressive symptoms as self-reported on the Beck Depression Inventory (BDI). Women having high BDI scores (reflecting significant depression) were more likely than men with high BDI scores to be diagnosed by their primary care physician (p = 0.0295). Female patients made significantly more visits to the clinic than men. For both sexes, patients with greater numbers of primary care clinic visits were more likely to be diagnosed as depressed. Logistic regression revealed that gender has both a direct and indirect (through increased use) effect on the likelihood of being diagnosed as depressed. Patient BDI score, clinic use, educational level, and marital status were all significantly related to the diagnosis of depression. Controlling all other independent variables, women were 72% more likely than men to be identified as depressed, but this effect did not achieve statistical significance (p = 0.0981). In gender-specific analyses, BDI and clinic use were again significantly related to the diagnosis of depression for both sexes. However, educational and marital status predicted depression diagnosis only for women. Separated, divorced, or widowed women were almost five times as likely to be diagnosed as depressed as those who were never married, all other factors being equal. Clinic use and BDI scores were found to be important correlates of the diagnosis of depression. There was some evidence of possible gender bias in the diagnosis of depression.

Background: Islet isolation from the pancreatic tissue matrix remains highly variable. Recent evidence suggests that intrinsic human pancreatic proteases, including trypsin, may inhibit effective collagenase enzymatic activity during islet isolation, thereby impairing the isolation success. In this study we have hypothesized that serine protease inhibition applied during pancreatic digestion, could improve yield and/or functional viability of islets isolated from human pancreases., Methods: Twelve organ donor pancreases with 12.9+/-0.6 hr cold storage (mean+/-SEM) were perfused via their ducts with Liberase-HI enzyme in the presence (n=6) or absence (n=6) of 0.4 mM Pefabloc. All were then gently dissociated and their purified islets separated with Ficoll density gradient centrifugation., Results: Donor-related factors (age, gender, cold storage time, body mass index, and pancreas weight) did not differ significantly between the two experimental groups. Pefabloc supplementation did not affect the digestion time, islets remaining trapped in exocrine tissue, or final islet purity. Islet recovery was increased in the Pefabloc-treated group (mean+/-SEM yield 323.8+/-80.8 x 10(3) islet equivalents vs. 130.8+/-13.6 x 10(3) islet equivalents, P<0.05). Cellular composition, DNA and insulin content, and insulin secretory activity of the isolated islets was similar., Conclusions: Inhibition of intrinsic protease activity within pancreases after prolonged cold storage improves isolation of viable islets.

The "devil is in the details" of any policy response. What forms such changes may take, and what research informs them, are critical to the profession as a whole and to practitioners on a daily basis. Research partnerships between home care agencies and university professors may provide rigorous, systematic, and validated findings necessary for meaningful solutions (Plotkin & Roche, 2000). The evidence of a dialogue between nursing researchers, home healthcare practitioners, and policymakers anticipating impacts on practice of changing fiscal and information-gathering requirements is scant. Such issues are in need a priority discussion by agencies, and collaborative investigative efforts between all involved.

In transplant rejection interferon (IFN)-gamma regulates the recipient immune response but also acts directly on IFN-gamma receptors in the graft. We investigated these direct actions by comparing rejecting kidneys from donors lacking IFN-gamma receptors (GRKO mice) or control donors (129Sv/J) in CBA recipients. Beginning day 5, 129Sv/J kidneys displayed high major histocompatibility complex (MHC) expression, progressive infiltration by inflammatory cells, but no thrombosis and little necrosis, even at day 21. GRKO kidneys showed increasing fibrin thrombi in small veins, peritubular capillary congestion, hyaline casts, and patchy parenchymal necrosis, progressing to near total necrosis at day 10. Terminal dUTP nick-end labeling assays were positive only in the interstitial infiltrate, confirming that massive cell death in GRKO transplants was not apoptotic. Paradoxically, GRKO kidneys showed little donor MHC induction and less inflammatory infiltration. Both GRKO and 129Sv/J allografts evoked vigorous host immune responses including alloantibody and mRNA for cytotoxic T cell genes (perforin, granzyme B, Fas ligand), and displayed similar expression of complement inhibitors (CD46, CD55, CD59). GRKO kidneys displayed less mRNA for inducible nitric oxide synthase and monokine inducible by IFN-gamma but increased heme oxygenase-1 mRNA. Thus IFN-gamma acting on IFN-gamma receptors in allografts promotes infiltration and MHC induction but prevents early thrombosis, congestion, and necrosis.

Background and Objectives: The number of US residents with limited English proficiency (LEP) is 14 million and rising. The goal of this study was to estimate the effects of LEP on physician time and resource use., Design: This was a prospective, observational study., Setting and Subjects: The study included 285 Medicaid patients speaking English (n = 112), Spanish (n = 62), or Russian (n = 111) visiting the General Medicine and Family Practice Clinics at the UC Davis Medical Center in 1996-1997 (participation rate, 85%). Bilingual research assistants administered patient questionnaires, abstracted the medical record, and conducted detailed time and motion studies., Main Outcome Measures: We used seemingly unrelated regression models to evaluate the effect of language on visit time, controlling for patient demographics and health status, physician specialty, visit type, and resident involvement in care. We also estimated the effect of LEP on cross-sectional utilization of health care resources and adherence to follow-up with referral and testing appointments., Results: The 3 language groups differed significantly by age, education, and reason for visit but not gender, number of active medical conditions, physical functioning, or mental health. Physician visit time averaged 38+/-20 minutes (mean+/-SD). Compared with English-speaking patients and after multivariate adjustment, Spanish and Russian speakers averaged 9.1 and 5.6 additional minutes of physician time, respectively (P <0.05). The language effect was confined largely to follow-up visits with resident physicians (house staff). Compared with English speakers, Russian speakers had more referrals (P = 0.003) and Spanish speakers were less likely to follow-up with recommended laboratory studies (P = 0.031)., Conclusions: In these academic primary care clinics, some groups of patients using interpreters required more physician time than those proficient in English Additional reimbursement may be needed to ensure continued access and high-quality care for this special population.

Continuity of patient care is a tenet of professional nursing practice regardless of setting. Communication between providers about patients is fundamental to continuity. As the role of hospitals in health care is constrained, care is now commonly delivered to patients during an episode of illness by multiple agencies. Continuity of care now assumes full communication between providers about patients' conditions and needs. Research provides evidence about the dynamics of patient care communication: more lean (background and medical) than rich (nursing care and psychosocial) data are communicated; structured, written formats transmit more information than informal channels of communication; and organizational and patient characteristics would appear to affect communication about patients. Knowledge about the communication dynamics of patient care may assist providers in designing strategies to attain the basic goals of continuity of care.

Little is known about home health agencies (HHA) and their integration in the continuum of care in rural areas. The aims of this study are to describe the amount and type of patient-related data transferred by discharging hospitals to rural HHAs and to explore the influence of selected organizational factors on that communication process using a previously tested model of interorganizational communication. In this study, 446 closed-case, elderly patient records at three rural HHAs were reviewed using the Referral Data Inventory. Rural HHAs receive about half of the literature-recommended referral data, characterized primarily by background data, some medical data, and almost no psychosocial or nursing-care data. Referrals transmitted by telephone and written data were superior to referrals transferred by a telephone call only. Hospital-affiliated HHAs received significantly greater amounts and richer types of referral data than did free-standing HHAs. Findings suggest that cost-saving measures in the referral process need investigation.

Background: Studies have shown that women use more health care services than men. We used important independent variables, such as patient sociodemographics and health status, to investigate gender differences in the use and costs of these services., Methods: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of health care services and associated charges were monitored for 1 year of care. Self-reported health status was measured using the Medical Outcomes Study Short Form-36 (SF-36). We controlled for health status, sociodemographic information, and primary care physician specialty in the statistical analyses., Results: Women had significantly lower self-reported health status and lower mean education and income than men. Women had a significantly higher mean number of visits to their primary care clinic and diagnostic services than men. Mean charges for primary care, specialty care, emergency treatment, diagnostic services, and annual total charges were all significantly higher for women than men; however, there were no differences for mean hospitalizations or hospital charges. After controlling for health status, sociodemographics, and clinic assignment, women still had higher medical charges for all categories of charges except hospitalizations., Conclusions: Women have higher medical care service utilization and higher associated charges than men. Although the appropriateness of these differences was not determined, these findings have implications for health care.

Objectives: To explore resident physician-patient interaction in primary care to address issues relevant to quality of care for older people., Design: A sample of 509 new, adult, nonpregnant patients was assigned to the care of second- and third-year residents in primary care clinics. Care was compared for three subgroups of patients: older patients (65 years or older; n = 45), those aged 18 to 44 years (n = 320), and those aged 45 to 64 years (n = 144)., Setting: Observations were made at the family medicine and general internal medicine clinics at the University of California, Davis., Measurements: Self-report by means of the Medical Outcomes Study Short Form-36 (MOS SF-36) was used to determine patient demographics and patient health status. Two measures of satisfaction were obtained gauging reaction to medical care in general and to the videotaped visit specifically. Videotapes were coded for content using the Davis Observation Code., Results: Self-reported health status of older persons was poorer than that of younger groups as measured by the MOS SF-36. Differences in demographics were explored and then controlled, along with physical health status in subsequent analyses. Supporting prior studies, this study found that older patients had more return visits and reported higher levels of satisfaction than did younger comparison groups. Contrary to prior literature, older patients were found to have longer visits than did younger cohorts. The physician-patient interaction was significantly different in many areas between these three groups. Whereas older patients experienced more chatting in their visits, they were given less counseling, asked fewer questions, had less discussion about their families and their use of substances, were asked to change their health behavior habits less often, and were given less health education. For older patients, more of each visit was spent checking on compliance with earlier treatment and developing treatment plans., Conclusions: These results provide a new and more detailed view of how resident physician-patient interaction differs between older and younger groups and raise important issues on whether quality of care needs for this population are being adequately addressed, particularly regarding mental health issues.

Background: Cyclosporine (CsA) acts by inhibiting the phosphatase calcineurin (CN), but the time course and extent of inhibition in vivo are unknown. We examined the effect of single oral CsA doses on CN activity in humans and mice in vivo., Methods: In humans, blood CsA levels were determined and CN activity was measured in whole blood and in blood leukocytes of patients up to 12 hr after CsA dosing (just before the second dose). Samples were collected from patients receiving a first single dose (2.5 mg/kg), and up to 14 days later after repeated dosing. In mice, after CsA dosing (12.5-200 mg/kg) by oral gavage, CsA levels in blood and tissue (spleen, kidney) were determined and CN activity was measured in spleen and kidney., Results: In humans, peak CsA levels of 800-2285 microg/L at 1-2 hr produced 70-96% CN inhibition. Inhibition correlated closely with the rise and fall of CsA levels with no observable lag at the times sampled. Repeated doses showed similar CN inhibition to first dose, with no significant adaptation. In mice, CsA peaked at 1 hr in blood, spleen, and kidney, with higher concentrations in spleen and kidney than in blood. CN inhibition closely followed CsA concentrations/doses, and was greater in kidney than spleen., Conclusion: Thus CsA induces partial CN inhibition that varies directly with the blood and tissue levels, and may be greater in some tissues due to higher drug accumulation. The high CsA concentrations and CN inhibition in kidney may be relevant to nephrotoxicity.

Background: The extensive literature concerning hospital readmissions is grounded in a medical or hospital perspective, and fails to address hospital readmissions during home care., Objectives: To describe clients who have unplanned returns to an inpatient setting during the first 100 days of home care service delivery., Method: Using the Hospital Readmission Inventory (HRI), an audit tool with previously established validity and reliability, 916 medical records for clients from 11 midwestern home care agencies were reviewed retrospectively., Results: Typically, clients were referred for their first home care admission after a 9-day hospital length of stay for a cardiovascular, respiratory, or neoplastic disorder. After an average 18-day length home care stay, clients were readmitted to the hospital, usually due to the development of a new problem, or due to deterioration in health status related to the primary or to a secondary medical diagnosis. Significant respiratory, cardiovascular or GI symptoms were generally present at hospital readmission. Typically, readmitted clients were 75 year old married females, who had been able to care for themselves at home. At hospital readmission, home care nurses judged these clients to be moderately ill, and likely in need of acute care., Conclusions: Chronic illness appears to be the best indicator for hospital readmission. The crucial time period for hospital readmission during home care is the first 2-3 weeks following hospital discharge. Intensive study of home care service arrangements utilized by readmitted patients, as well as agency variations, are needed. Study findings concerning patients readmitted from home care point to similarities with rehospitalized patients generally. Findings may assist home care clinicians in targeting high risk patients who could benefit from interventions aimed at minimizing unplanned returns to the hospital.

New adult patients (n = 212) were randomly assigned to 58 primary care resident physicians. Physician practice styles during initial and return visits were analyzed using the Davis Observation Code. Compared with initial patient visits, return visits were shorter, but more work-intensive. Return visits displayed significantly less technically oriented behavior (including history taking, physical examination, and treatment planning) and fewer discussions regarding use of addictive substances; however, there was more emphasis on health behaviors and active involvement of patients in their own care. These physicians' practice style differences between initial and return patient visits suggest that physician-patient familiarity affects what happens during the medical interview.

Objectives: To estimate costs for the prevention and treatment of cervical cancer based on resource utilization and to compare those costs to published estimates and to local charges and reimbursements., Design: Cost estimates for cervical cancer prevention services were based on clinic staff time, use of specialized equipment and supplies, laboratory costs, and clinic overhead. Cost estimates for cervical cancer treatment were based on HMO expenditures for cervical cancer patients and control patients. These costs were adjusted for stage distribution and survival rates. Published cost estimates were obtained from a systematic review of the medical literature between 1990 and 1996., Setting: Three family planning clinics (for prevention costs) and a staff-model HMO (for treatment costs)., Patients: For treatment costs: 98 cervical cancer patients and 133,058 female control patients, matched by age and chronic disease score., Main Outcome Measures: Estimated costs for prevention and treatment of cervical cancer. Cost-to-charge and cost-to-reimbursement ratios., Results: Costs of cervical cancer prevention and treatment services have been determined using a variety of methods. We found substantial variation in these estimates, even for studies with similar methodologies. Detailed resource-based estimation suggests that prevention costs are generally lower than those previously published in the literature, whereas the costs of cervical cancer treatment are generally higher., Conclusions: It is practical and desirable to employ resource use-based estimates of medical costs in cost-effectiveness analyses. Failure to do so for cervical cancer may affect policy recommendations by understating the relative benefits of prevention programs.

Background and Objectives: This paper examines the practice style patterns of family practice and internal medicine residents for established patient visits., Methods: New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care by resident physicians. Initial and return visits were videotaped, and physician practice styles were analyzed using the Davis Observation Code (DOC)., Results: Resident physicians' practice styles with established patients during return visits were associated with various factors, depending on the DOC cluster of behaviors studied. These factors include patient gender, age, income, physical and mental health status, level of pain, number of return visits, and physician practice style displayed during the initial encounter. Family practice return visits had a greater emphasis on preventive services and counseling, compared with internal medicine return visits. Internists spent more visit time using technically oriented behaviors., Conclusions: Patient variables, as well as baseline physician behavior, have an important influence on physician practice styles during return patient visits. There are measurable differences in the established practice styles between family practice and internal medicine resident physicians, which may reflect differences in professional training programs.

Objectives: Data from 509 primary care patients were analyzed to determine whether practice style differences between family physicians and general internists generate differential utilization of health care resources leading to differential medical charges., Methods: New adult patients were prospectively randomized to care by family physicians and general internists. Utilization of medical care services and associated charges then were monitored for 1 year of care., Results: Family practice patients had a significantly higher mean number of visits to their primary care clinic and significantly fewer emergency room visits than patients assigned to Internal Medicine. Mean charges for primary care and emergency department treatment were significantly lower for patients assigned to Family Practice than for those assigned to General Internal Medicine. There were no significant differences in charges for specialty clinic visits, hospitalizations, or diagnostic services., Conclusions: Practice style differences between family physicians and general internists were associated with differential medical charges, with family physicians generating lower charges for some aspects of care.

Background: There are differences in styles of care among primary care physicians. The purpose of our study was to determine whether differences in physician practice styles and patient health status generate different medical charges., Methods: New adult patients (N = 509) were randomized to primary care physicians, and use of medical care services and associated charges were monitored for 1 year., Results: Controlling for baseline patient health status, a technically oriented style of care was associated with significantly higher specialty care, emergency department, diagnostic, and total charges. Some practice behaviors, however, were associated with lower charges; for example, a practice style emphasizing patient activation was associated with significantly lower primary care charges. Both a lower baseline patient health status and a health status that declined over the study period predicted higher charges., Conclusions: Measurable differences in practice style are associated with differing medical care charges. Patients' health status was also an important determinant of medical charges and had implications for the assessment of physician utilization patterns.

The purpose of this study was to describe the influence of selected organizational and medical factors on communication between hospitals and extended care facilities (ECF) in the referral of elderly clients following discharge from acute care. Using a tool with previously established reliability and validity, 455 closed records of referral were purposively selected and reviewed for the amount and type of information an ECF received upon referral, as well as selected organizational and medical factors. Hospitals transferred approximately three-fourths of the patient care data recommended in the literature. Information contained in an ECF referral consisted primarily of background and medical data, with some nursing care data and limited psychosocial data. More information-rich referrals were generated by very large hospitals and by specialty care units. Similarly, proprietary ECFs received more patient care data than their not-for-profit counterparts. Research concerning patient care communication between provider organizations across the health care delivery system may assist nurses in developing better patient care information-management systems.

Affirmative action policies are under challenge. To date, judicial concerns must be understood historically. The legal question is to define the conditions under which racial categories may be used for remedial or beneficial purposes to overcome the effects of past discrimination. Beyond exercising strict scrutiny over the use of racial classifications, courts have supported the diversification of academe. For nursing programs, the challenge is to develop policies and procedures to broaden participation without reliance on racial categories. The benefits of diversifying the nursing work force need not be discarded in response to judicial and political reaction to affirmative action.

Objectives: This study compared patient health status, patient satisfaction, and physician practice style between family practice and internal medicine., Methods: New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care. Practice styles were characterized by the Davis Observation Code. Self-reported health status (Medical Outcomes Study, Short Form-36) and patient satisfaction also were measured., Results: There were no significantly different changes in self-reported health status or patient satisfaction between family practice and internal medicine physicians during the course of the study. Family practice initial encounters, however, were characterized by a style placing greater relative emphasis on health behavior and counseling, whereas internists used a more technical style. Improved health status scores after treatment were predicted by a practice style emphasis on counseling, whereas improvements in patient satisfaction scores were predicted by a style of care stressing patient activation. Although this is the first known randomized trial studying this issue, the conclusions are limited by a 38% loss of patients from enrollment to care and a loss of 18% at the 1-year follow-up evaluation., Conclusions: There were significant differences in practice styles between family physicians and internists; however, it was the physician's behavior, not specialty per se, that affected patient outcomes. A practice style emphasizing psychosocial aspects of care was predictive of improvements in patient health status, whereas a practice style emphasizing patient activation was predictive of improvements in patient satisfaction.

Home health care costs have increased more than any other health care service covered by Medicare, and new methods of payment by Medicare are being introduced. A prospective payment system would replace the per visit rate now paid to home care agencies by Medicare. In order to remain viable under a new payment system, home health care agencies will need to be efficient in the delivery of home care services and still demonstrate effective patient care. The intent of this descriptive study was to determine norms of resource utilization for the congestive heart failure (CHF) patients admitted and discharged from a not-for-profit home health agency (HHA). Forty agency records were retrospectively reviewed using the Resource Utilization Inventory to collect the characteristics and resource utilization of the sample group. The CHF patients were older than most home care clients and had chronic health problems. Because of these chronic health problems, over half of the study population had caregivers so that the clients could remain in their own homes. Most clients clearly demonstrated the need for skilled nursing or home health aide visits after being hospitalized for an acute CHF episode. Less than half of the study group were discharged form the HHA as improved, and frequently were discharged to another healthcare facility. These results provide a beginning direction for profiling the CHF patient's consumption of resources for setting prospective reimbursement rates.

Objective: The purpose of this study was to assess the need for home health care referral screening for elderly patients after ED discharge. The specific research question addressed was: Is there a need for home care referral screenings for elderly patients discharged from the emergency department?, Design: A nonexperimental, retrospective, descriptive design was used in this project., Methods: A convenience sample of 194 closed medical records was obtained from a Midwestern hospital emergency department. The medical records were from patients 65 years of age and older who had visited the emergency department during a 3-month period. One chart audit tool was completed for each medical record., Results: Eighty-eight (45.4%) of the 194 patients in the study could have benefited from a home care referral., Conclusion: Elderly patients frequently access the health care delivery system through the emergency department, but little is known about the outcomes of such usage, particularly in the context of continuity of care. If home care referral screenings of elderly ED patients are performed and appropriate referrals are made before ED discharge, a seamless delivery system of health care is provided. A home care visit resulting from a referral may be all that is needed for the maintenance of a patient's condition. To improve the quality and continuity of patient care, home care screening should be integrated into the routine discharge ED activities.

The use of affirmative action programs as part of the effort to increase the presence of minorities in medical education and the physician workforce has come under greater legal scrutiny. The authors describe the history of the legal theory behind affirmative action, giving examples from the evolving case law and from Department of Education guidelines. They identify legal pitfalls in the areas of admission and financial aid, including the categorization of students by race, racially disproportionate financial aid awards after accounting for need, racially disproportionate amounts of scholarships as opposed to loans, and, for public medical schools, differential treatment of out-of-state students based on race. Medical schools should be aware of this legal framework so that they can construct affirmative action programs that comply with the law while maintaining momentum toward diversification.

Purpose: To describe and compare the patient-care communication exchanged between personnel in hospitals and nursing homes (NHs) and hospitals and home health agencies (HHAs) in referrals of elderly patients using an adaptation of classic communication theory. Little research on patient-care communication across organizational settings has been reported. This study offers baseline information about inter-organizational communication and insight into barriers to patient care communication., Design: A retrospective, descriptive study using a convenience sample of 455 medical records of referrals to NHs and 300 to HHAs., Methods: Medical records were audited and a Referral Data Inventory (with established reliability and validity) was completed for each of the records reviewed. Data were collected between January and June 1995., Findings: Greater amounts of referral data were transferred to NHs, than to HHAs. Patient information was composed largely of background and medical data, followed by some nursing care data and limited psychosocial data. Hospitals employed more formal channels of communication in referring patients to NHs than to HHAs, and communicated information more promptly. Some organizational factors related to both the referring hospitals and receiving organizations resulted in discrepancies in patient-care communication., Conclusions: Continuity of patient care involves a series of coordinating linkages across time, settings, providers, and consumers of health care. Communication is a core task in coordinating patient care. Increased and improved inter-organizational communication is needed when patients are discharged to nursing homes or home health agencies.