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Objective: Assess effects of a bedside interpreter-phone intervention on hospital discharge preparedness among patients with limited English proficiency (LEP)., Methods: Mixed-methods study compared patient-reported discharge preparedness and knowledge of medications and follow-up appointments among 189 Chinese- and Spanish-speakers before (n=94) and after (n=95) bedside interpreter-phone implementation, and examined nurse and resident-physician interpreter-phone utilization through focus groups., Results: Pre-post discharge preparedness (Care Transitions Measure mean 77.2 vs. 78.5; p=0.62) and patient-reported knowledge of follow-up appointments, discharge medication administration and side effects did not differ significantly. Pre-post knowledge of medication purpose increased in bivariate (88% vs. 97%, p=0.02) and propensity score adjusted analyses [aOR (adjusted odds ratio), 4.49; 95% CI, 1.09-18.4]. Nurses and physicians reported using interpreter-phones infrequently for discharge communication, preferring in-person interpreters for complex discharges and direct communication with family for routine discharges. Post-implementation patients reported continued use of ad-hoc family interpreters (43%) or no interpretation at all (22%)., Conclusion: Implementation of a bedside interpreter-phone systems intervention did not consistently improve patient-reported measures of discharge preparedness, possibly due to limited uptake during discharges., Practice Implications: Hospital systems must better understand clinician preferences for discharge communication to successfully increase professional interpretation and shift culture away from using family members as interpreters., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: In the Re-NOVATE II study, oral dabigatran provided thromboprophylaxis after total hip arthroplasty and improved compliance postdischarge in a global population. This article aims to identify trends (if any) in the Indian population., Methods: In this prospective, double-blind, double-dummy study, patients scheduled for primary, unilateral, elective total hip arthroplasty were randomized to 220 mg oral dabigatran once daily, starting with a 110 mg half-dose, 1-4 hours after surgery, or subcutaneous enoxaparin 40 mg once daily, starting the evening before surgery. Each group received a placebo of the other study drug. The primary efficacy outcome was the composite of total venous thromboembolism (VTE) and all-cause mortality. Secondary outcome measures were composite of major VTE and VTE-related mortality during the treatment period. The major safety outcome was incidence of bleeding events., Results: Of the 179 Indian patients randomized, 91 received oral dabigatran and 88 received subcutaneous enoxaparin for 28-35 days. Total VTE and all-cause mortality occurred in 18.7% of patients in the dabigatran group and 13.7% in the enoxaparin group [odds ratio = 1.4 (95% confidence interval 0.6, 3.5)]. Major VTE and VTE-related mortality was numerically lower in the dabigatran group (7.9%) compared with the enoxaparin group (9.9%). Safety outcomes were comparable between both groups., Conclusion: Dabigatran is an effective oral alternative to enoxaparin for thromboprophylaxis as demonstrated by the RE-NOVATE II study global results. Data analyzed in Indian patients indicate comparable effects of dabigatran etexilate for major efficacy and safety outcomes., (Copyright © 2017. Published by Elsevier Taiwan.)

Cisplatin and paclitaxel both can cause peripheral neurotoxicity as an adverse effect; however, central nervous system neurotoxicity in the form of seizures is rare. We report a case of a 36-year-old female patient of metastatic carcinoma cervix, who developed seizure shortly after cisplatin infusion. Her laboratory investigations were within normal limits. Computed tomography scan and magnetic resonance imaging of the brain did not reveal brain primary metastasis or meningeal carcinomatosis. She had no complaints of fever, no signs and symptoms of infection, and no history of seizure nor was she on any medication predisposing to such an event. Excluding several causes, seizure was thought to be most likely related to the chemotherapy and cisplatin was the more likely agent in view of observed temporal relationship with the adverse event., Competing Interests: There are no conflicts of interest.

We report a case of penile carcinoma presenting as an inguinal bubo in a young man. The associated painful genital ulcer and history of high-risk sexual behaviour raised a strong suspicion of a sexually transmitted infection. We review the literature for similar cases, highlight the similarities with venereal disease and discuss the differential diagnosis of inguinal bubo., (© The Author(s) 2016.)

The quality domains of patient-centered and equitable care are increasingly relevant to today's healthcare leaders as hospitals care for patients with increasingly diverse cultural and linguistic needs. Hospital leaders face substantial tensions in defining their organization's strategic priorities to improve care for diverse populations with limited resources, increased competition, and complex regulatory and accreditation requirements. We sought to understand what motivates hospitals to focus on and commit resources to supporting the delivery of culturally competent care by analyzing interviews with chief executive officers (CEOs) in 60 hospitals across the United States. Hospital CEOs in our study most often embraced cultural competence efforts because doing so helped them achieve the organization's mission and priorities and/ or meet the needs of a particular patient population. Less often, they were motivated by perceived benefits and legal or regulatory issues. Many CEOs articulated a link between quality and cultural competence, and a smaller number went on to link cultural competence efforts to improved financial outcomes through cost savings, increased market share, and improved efficiency of care. However, the link between quality and cultural competence is still in the early stages. Fortunately, frameworks for hospitals to adopt and steps that hospitals can take to improve the quality of care for all patients have been identified. They begin with a commitment from hospital leaders based on understanding the needs of patients and communities and are propelled by data that reveal the impact of efforts to improve care. Leaders must communicate and shepherd organizations to align the congruence between improvement efforts and business strategies.

Provision of language services is central to the delivery of equitable, safe, high-quality health care for patients with limited English proficiency. However, there are many barriers to ensuring access to such services. We analyzed the experience of a model language service program at a public hospital to develop recommendations applicable to all hospitals that wish to create an effective language service program. Our case study demonstrates that with organizational commitment, early information technology involvement, attention to clinical needs, active engagement of stakeholders, and coordinated project management, it is possible to provide high-quality language services in a setting of financial constraints.

Objectives: To develop, implement, and evaluate the impact of a cultural competence train-the-trainer workshop for pharmacy educators., Methods: A 2-day train-the-trainer workshop entitled Incorporating Cultural Competency in Pharmacy Education (1.65 CEUs) was provided to pharmacy faculty from schools across the United States. Baseline, posttraining, and 9-month follow-up surveys assessed participants' (n = 50) characteristics and self-efficacy in developing and teaching content., Results: At baseline, 94% of faculty members reported no formal training in teaching cultural competence. After completing the workshop, participants' self-rated confidence for developing and teaching workshop content significantly increased. The number of participants who rated their ability to teach cultural competence as "very good" or "excellent" increased from 13% to 60% posttraining. Participants reported teaching 1 or more aspects of the workshop curriculum to nearly 3,000 students in the 9-months following training., Conclusions: The workshop significantly increased faculty members' perceived and documented ability to teach cultural competence. The train-the-trainer model appears to be a viable and promising strategy for meeting the American Council for Pharmacy Education accreditation standards relating to the teaching of diversity, cultural issues, and health literacy.

Objective: To determine if professional medical interpreters have a positive impact on clinical care for limited English proficiency (LEP) patients., Data Sources: A systematic literature search, limited to the English language, in PubMed and PsycINFO for publications between 1966 and September 2005, and a search of the Cochrane Library., Study Design: Any peer-reviewed article which compared at least two language groups, and contained data about professional medical interpreters and addressed communication (errors and comprehension), utilization, clinical outcomes, or satisfaction were included. Of 3,698 references, 28 were found by multiple reviewers to meet inclusion criteria and, of these, 21 assessed professional interpreters separately from ad hoc interpreters. Data were abstracted from each article by two reviewers. Data were collected on the study design, size, comparison groups, analytic technique, interpreter training, and method of determining the participants' need for an interpreter. Each study was evaluated for the effect of interpreter use on four clinical topics that were most likely to either impact or reflect disparities in health and health care., Principal Findings: In all four areas examined, use of professional interpreters is associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to raise the quality of clinical care for LEP patients to approach or equal that for patients without language barriers., Conclusions: Published studies report positive benefits of professional interpreters on communication (errors and comprehension), utilization, clinical outcomes and satisfaction with care.

The potential for discarded electronic devices to be classified as toxicity characteristic (TC) hazardous waste under provisions of the Resource Conservation and Recovery Act (RCRA) using the toxicity characteristic leaching procedure (TCLP) was examined. The regulatory TCLP method and two modified TCLP methods (in which devices were disassembled and leached in or near entirety) were utilized. Lead was the only element found to leach at concentrations greater than its TC limit (5 mg/L). Thirteen different types of electronic devices were tested using either the standard TCLP or modified versions. Every device type leached lead above 5 mg/L in at least one test and most devices leached lead above the TC limit in a majority of cases. Smaller devices that contained larger amounts of plastic and smaller amounts of ferrous metal (e.g., cellular phones, remote controls) tended to leach lead above the TC limit at a greater frequency than devices with more ferrous metal (e.g., computer CPUs, printers).

Many U.S. residents who speak little English may face language barriers when seeking health care. This article describes what is currently known about language barriers in health care and outlines a research agenda based on mismatches between the current state of knowledge of language barriers and what health care stakeholders need to know. Three broad areas needing more research are discussed: the ways in which language barriers affect health and health care, the efficacy of linguistic access service interventions, and the costs of language barriers and efforts to overcome them. In each of these areas, we outline specific research questions and recommendations.

Purpose: To create a framework for teaching the knowledge and skills of practice-based learning and improvement to medical students and residents based on proven, effective strategies., Method: The authors conducted a Medline search of English-language articles published between 1996 and May 2001, using the term "quality improvement" (QI), and cross-matched it with "medical education" and "health professions education." A thematic-synthesis method of review was used to compile the information from the articles. Based on the literature review, an expert panel recommended educational objectives for practice-based learning and improvement., Results: Twenty-seven articles met the inclusion criteria. The majority of studies were conducted in academic medical centers and medical schools and 40% addressed experiential learning of QI. More than 75% were qualitative case reports capturing educational outcomes, and 7% included an experimental study design. The expert panel integrated data from the literature review with the Dreyfus model of professional skill acquisition, the Institute for Healthcare Improvement's (IHI) knowledge domains for improving health care, and the ACGME competencies and generated a framework of core educational objectives about teaching practice-based learning and improvement to medical students and residents., Conclusion: Teaching the knowledge and skills of practice-based learning and improvement to medical students and residents is a necessary and important foundation for improving patient care. The authors present a framework of learning objectives-informed by the literature and synthesized by the expert panel-to assist educational leaders when integrating these objectives into a curriculum. This framework serves as a blueprint to bridge the gap between current knowledge and future practice needs.

Reactive arthritis is associated with demonstrable infection at a distant site without evidence of sepsis at the affected joint(s). We present a rare case reactive arthritis where no bacterial or chlamydial infections could be established, rather larvae of Strongyloides stercoralis could be demonstrated in the stool and duodenal biopsy. Reactive arthritis, psoriasiform lesions and malabsorption with hypoproteinaemia, responded to successful treatment with antihelminthic drugs. Early recognition and adequate treatment for gastrointestinal infections and infestations before complications is important.

Purpose: Block ambulatory rotations and longitudinal ambulatory care experiences are now common in U.S. medical schools, but little is known about their efficacy. Through a structured review of the medical literature from 1966 through March 2000, the authors summarize the characteristics of, the evidence for, and the evaluation of longitudinal ambulatory care rotations., Method: The authors searched Medline using the terms "outpatients," "continuity of patient care," "ambulatory care," "mentors," "preceptorship," "graduate medical education," "curriculum," and "clinical clerkship" cross-matched to "medical students" and "internship and residency" for literature published from 1966 through March 2000. They narrowed the list to only articles containing empirical outcome data focusing on medical students' experiences in longitudinal ambulatory care rotations. Each study was scored to assess its strengths and weaknesses., Results: Seven articles met the search criteria. The articles identified the benefits of longitudinal ambulatory care experiences, including developing effective patient interactions and understanding chronic diseases. There were little or no differences in the students' overall knowledge acquisition when those with longitudinal experiences were compared with those in block rotations., Discussion: Although longitudinal ambulatory care experiences are now common in medical schools, evidence supporting their widespread implementation is sparse. Few studies employ rigorous methods to evaluate educational outcomes. Research to identify benefits and costs, improve the quality and consistency of the students' experiences, and develop other innovative ways of teaching and learning ambulatory care is needed.

Health care provider-patient role relationships can influence patient satisfaction, adherence to treatment, and health outcomes positively. Existing models of role relationships reflect one of three approaches to clinical management--paternalism, consumerism, or shared decision making. These models may or may not reflect the reality of chronic disease management in clinical practice. To characterize the nature of chronic disease management from the perspectives of primary care providers, we asked four nurse practitioners and four internists to describe the roles they saw for themselves and for their patients. A qualitative approach using a descriptive mode supported the formulation of a narrative description of these roles. The roles reflected a paternalistic approach to chronic disease management. The shared decision making approach supported in the literature was not evident. This finding is important for health professional education and practice.

Diagnosis of Hodgkin's disease is made with more confidence than diagnosis of non-Hodgkin's lymphoma on cytology. This study was undertaken to describe the presence of granulomas and a new cytologic feature, discrete epithelioid cells (DECs), in smears from Hodgkin's disease. Fine-needle aspiration smears from 39 cases of biopsy-proven Hodgkin's disease, collected over a period of 43 months, were reviewed. Epithelioid granulomas were seen in 38.5% of the smears. DECs, which were noted in 70% of the cases, may be useful in raising the suspicion of Hodgkin's disease when other features are not evident; their presence should encourage the cytopathologist to obtain aspirations from other lymph nodes., (Copyright 2002 Wiley-Liss, Inc.)

Observation of surgical personnel in four specialties (cardiothoracic, general, gynecologic, and orthopedic) in the operating room was performed prior to implementation of an educational intervention designed to improve compliance with Universal Precautions and at 1- and 2-years post-intervention. Use of protective eyewear and double gloving increased following the intervention, whereas the incidence of documented blood and body fluid exposures decreased.

Background: Little is known about long-term improvements in medical students' knowledge, attitudes, and use of blood and body fluid precautions following preclinical training., Methods: We evaluated an educational and skills-training program emphasizing double gloving for high-risk surgical procedures. Baseline surveys measuring knowledge, attitudes, and readiness to use specific precautions were completed by second-year (experimental) students before skills training and by third-year students (control) after their first clinical year. Follow-up surveys were completed 1 year later. Use of double gloves and protective eyewear during surgery clerkships was observed at baseline and follow-up., Results: Of 149 students returning both surveys, the experimental group (n = 91) showed improvements in attitudes toward double gloving (P = 0.038) and use of double gloves during surgery at follow-up (relative risk = 1.95, 95% confidence interval = 1.06, 3.59). They expressed better attitudes toward (P = 0.003) and greater readiness to use (P = 0. 020) double gloves compared with controls at follow-up. They expressed better attitudes toward (P = 0.002) and greater readiness to use (P = 0.001) double gloves compared with controls when each had completed their first clinical year., Conclusion: The intervention was associated with improved attitudes toward and use of double gloves during surgery. The experimental group also expressed better attitudes and readiness to use double gloves compared with controls at follow-up., (Copyright 1999 American Health Foundation and Academic Press.)

Study Objective: Emergency department personnel are at high risk of occupational infection with bloodborne pathogens. The objective of this study was to observe and analyze the use of barrier precautions among ED personnel caring for trauma patients., Methods: This observational study used videotapes of trauma cases seen at an urban Level I trauma center. Study participants were ED and trauma team personnel. Trained observers scored breaks in the use of barrier precautions during the first 15 minutes of 88 videotaped Level I trauma cases. "Major" breaks were scored when ED personnel performed invasive procedures without gloves, mask, gown, and adequate eye protection. "Minor" breaks were scored when ED personnel were adjacent to a trauma patient (within 1 m) without wearing these items., Results: We observed 1 or more major breaks in 33.6% of 304 invasive procedures. The most common major break was failure to wear a mask (32.2% of procedures), followed by inadequate eyewear (22.2%), no gown (5.6%), and no gloves (3.0%). We observed minor breaks during 55.5% of 752 patient encounters. Large and statistically significant variations were seen in use rates of barrier precautions among different groups of personnel; surgery residents were most likely to use precautions, whereas attending surgeons were least likely., Conclusion: Compliance with universal precautions is poor in this high-risk clinical setting. These data provide a baseline for measuring the effectiveness of interventions to improve compliance. Videotaped observations are a novel and effective tool in this setting.

Objective: To evaluate Universal Precautions (UP) compliance in the operating room (OR)., Design: Prospective observational cohort. Trained observers recorded information about (1) personal protective equipment used by OR staff; (2) eyewear, glove, or gown breaks; (3) the nature of sharps transfers; (4) risk-taking behaviors of the OR staff; and (5) needlestick injuries and other blood and body-fluid exposures., Setting: Barnes-Jewish Hospital, a 1,000-bed, tertiary-care hospital affiliated with Washington University School of Medicine, St Louis, Missouri., Participants: OR personnel in four surgical specialties (gynecologic, orthopedic, cardiothoracic, and general). Procedures eligible for the study were selected randomly. Hand surgery and procedures requiring no or a very small incision (eg, arthroscopy, laparoscopy) were excluded., Results: A total of 597 healthcare workers' procedures were observed in 76 surgical cases (200 hours). Of the 597 healthcare workers, 32% wore regular glasses, and 24% used no eye protection. Scrub nurses and medical students were more likely than other healthcare workers to wear goggles. Only 28% of healthcare workers double gloved, with orthopedic surgery personnel being the most compliant. Sharps passages were not announced in 91% of the surgical procedures. In 65 cases (86%), sharps were adjusted manually. Three percutaneous and 14 cutaneous exposures occurred, for a total exposure rate of 22%., Conclusion: OR personnel had poor compliance with UP. Although there was significant variation in use of personal protective equipment between groups, the total exposure rate was high (22%), indicating the need for further training and reinforcement of UP to reduce occupational exposures.

Objective: To investigate differences in second-, third-, and fourth-year medical students' knowledge of bloodborne pathogen exposure risks, as well as their attitudes toward, and intentions to comply with, Universal Precautions (UP)., Design: Cross-sectional survey., Participants and Setting: Surveys about students' knowledge, attitudes, and intentions to comply with UP were completed by 111 second-year (preclinical), 80 third-year, and 60 fourth-year medical students at Washington University School of Medicine in the spring of 1996., Results: Preclinical students knew more than clinical students about the efficacy of hepatitis B vaccine, use of antiretroviral therapy after occupational exposure to human immunodeficiency virus, and nonvaccinated healthcare workers' risk of infection from needlestick injuries (P<.001). Students' perceived risk of occupational exposure to bloodborne pathogens and attitudes toward hepatitis B vaccine did not differ, but preclinical students agreed more strongly that they should double glove for all invasive procedures with sharps (P<.001). Clinical students agreed more strongly with reporting only high-risk needlestick injuries (P=.057) and with rationalizations against using UP (P=.008). Preclinical students more frequently reported contemplating or preparing to comply with double gloving, wearing protective eyewear, reporting all exposures, and safely disposing of sharps, whereas students with clinical experience were more likely to report compliance. Clinical students also were more likely to report having "no plans" to practice the first three of these precautions (P<.001)., Conclusions: Differences in knowledge, attitudes, and intentions to comply with UP between students with and without clinical experience may have important implications for the timing and content of interventions designed to improve compliance with UP.

We describe variations in healthcare workers' attitudes toward double gloving and reporting needlesticks, and in their readiness to comply with double gloving and hepatitis B vaccine. Differences related to occupation, specialty, and gender have implications for the need to tailor interventions for specific groups of healthcare workers to improve compliance with Universal Precautions.

As the country strives to produce larger numbers of generalist physicians, considerable controversy has arisen over whether or not generalist applicants can be identified, recruited, and influenced to keep a generalist-oriented commitment throughout medical training. The authors present new and existing data to show that: 1) preadmission (BA/MD or post-baccalaureate) programs can help to identify generalist-oriented students; 2) characteristics determined at admission to medical school are predictive of future generalist career choice; 3) current inpatient-oriented training programs strongly push students away from a primary care career; 4) women are more likely than men to choose generalist careers, primarily because of those careers' interpersonal orientation; and 5) residency training programs are able to select applicants likely to become generalists. Therefore, to produce more generalists, attempts should be made to encourage generalist-oriented students to enter medical schools and to revise curricula to focus on outpatient settings in which students can establish effective and satisfying relationships with patients. These strategies are most likely to be successful if enacted within the context of governmental and medical school-based changes that allow for more reimbursement and respect for the generalist disciplines.

The mature erythrocyte has a cytoskeleton of less complexity than that of nucleated cells and has been elucidated in greater detail. Two of its major components are the heterodimeric protein spectrin and protein 4.1. We report here our isolation from human keratinocytes of immunoreactive forms of both protein 4.1 and of alpha-fodrin, the extra-erythrocytic form of alpha-spectrin. These keratinocyte proteins are approximately 125 kD and 240 kD in size, respectively. We also have isolated clones containing alpha-fodrin and protein 4.1 sequences from a human keratinocyte cDNA library. These sequences confirm the active transcription in keratinocytes of the alpha-fodrin and protein 4.1 genes. Both alpha-fodrin and protein 4.1 mRNA are detectable by Northern blot analysis in human keratinocytes, where their abundance appears not to be regulated by calcium concentration in the medium.

Solid-state anomalies in the IR spectra of lysine monohydrochloride, etoxadrol hydrochloride, thiamine hydrochloride, and L-histidine in a potassium bromide matrix were noted. With the first three compounds, the anomalies were due to metathetical exchange of the halide anion between the compound and the matrix. The anomaly seen with L-histidine was related to the crystal structure.