Improving Youth Suicide Risk Screening and Assessment in a Pediatric Hospital Setting by Using The Joint Commission Guidelines.

OBJECTIVES: Hospitals accredited by The Joint Commission (TJC) are now required to use a validated screening tool and a standardized method for assessment of suicide risk in all behavioral health patients. Our aims for this study were (1) to implement a TJC-compliant process of suicide risk screening and assessment in the pediatric emergency department (ED) and outpatient behavioral health clinic in a large tertiary care children's hospital, (2) to describe characteristics of this population related to suicide risk, and (3) to report the impact of this new process on ED length of stay (LOS). METHODS: A workflow using the Columbia Suicide Severity Rating Scale was developed and implemented. Monthly reviews of compliance with screening and assessment were conducted. Descriptive statistics were used to define the study population, and multivariable regression was used to model factors associated with high suicide risk and discharge from the ED. ED LOS of behavioral health patients was compared before and after implementation. RESULTS: Average compliance rates for screening was 83% in the ED and 65% in the outpatient clinics. Compliance with standardized assessments in the ED went from 0% before implementation to 88% after implementation. The analysis revealed that 72% of behavioral health patients in the ED and 18% of patients in behavioral health outpatient clinics had a positive suicide risk. ED LOS did not increase. The majority of patients screening at risk was discharged from the hospital after assessment. CONCLUSIONS: A TJC-compliant process for suicide risk screening and assessment was implemented in the ED and outpatient behavioral health clinic for behavioral health patients without increasing ED LOS.

Direct Observation Assessment of Milestones: Problems with Reliability.

INTRODUCTION: Emergency medicine (EM) milestones are used to assess residents' progress. While some milestone validity evidence exists, there is a lack of standardized tools available to reliably assess residents. Inherent to this is a concern that we may not be truly measuring what we intend to assess. The purpose of this study was to design a direct observation milestone assessment instrument supported by validity and reliability evidence. In addition, such a tool would further lend validity evidence to the EM milestones by demonstrating their accurate measurement. METHODS: This was a multi-center, prospective, observational validity study conducted at eight institutions. The Critical Care Direct Observation Tool (CDOT) was created to assess EM residents during resuscitations. This tool was designed using a modified Delphi method focused on content, response process, and internal structure validity. Paying special attention to content validity, the CDOT was developed by an expert panel, maintaining the use of the EM milestone wording. We built response process and internal consistency by piloting and revising the instrument. Raters were faculty who routinely assess residents on the milestones. A brief training video on utilization of the instrument was completed by all. Raters used the CDOT to assess simulated videos of three residents at different stages of training in a critical care scenario. We measured reliability using Fleiss' kappa and interclass correlations. RESULTS: Two versions of the CDOT were used: one used the milestone levels as global rating scales with anchors, and the second reflected a current trend of a checklist response system. Although the raters who used the CDOT routinely rate residents in their practice, they did not score the residents' performances in the videos comparably, which led to poor reliability. The Fleiss' kappa of each of the items measured on both versions of the CDOT was near zero. CONCLUSION: The validity and reliability of the current EM milestone assessment tools have yet to be determined. This study is a rigorous attempt to collect validity evidence in the development of a direct observation assessment instrument. However, despite strict attention to validity evidence, inter-rater reliability was low. The potential sources of reducible variance include rater- and instrument-based error. Based on this study, there may be concerns for the reliability of other EM milestone assessment tools that are currently in use.

Molecular transitions from papillomavirus infection to cervical precancer and cancer: Role of stromal estrogen receptor signaling.

To study the multistep process of cervical cancer development, we analyzed 128 frozen cervical samples spanning normalcy, increasingly severe cervical intraepithelial neoplasia (CIN1- CIN3), and cervical cancer (CxCa) from multiple perspectives, revealing a cascade of progressive changes. Compared with normal tissue, expression of many DNA replication/repair and cell proliferation genes was increased in CIN1/CIN2 lesions and further sustained in CIN3, consistent with high-risk human papillomavirus (HPV)-induced tumor suppressor inactivation. The CIN3-to-CxCa transition showed metabolic shifts, including decreased expression of mitochondrial electron transport complex components and ribosomal protein genes. Significantly, despite clinical, epidemiological, and animal model results linking estrogen and estrogen receptor alpha (ERα) to CxCa, ERα expression declined >15-fold from normalcy to cancer, showing the strongest inverse correlation of any gene with the increasing expression of p16, a marker for HPV-linked cancers. This drop in ERα in CIN and tumor cells was confirmed at the protein level. However, ERα expression in stromal cells continued throughout CxCa development. Our further studies localized stromal ERα to FSP1+, CD34+, SMA- precursor fibrocytes adjacent to normal and precancerous CIN epithelium, and FSP1-, CD34-, SMA+ activated fibroblasts in CxCas. Moreover, rank correlations with ERα mRNA identified IL-8, CXCL12, CXCL14, their receptors, and other angiogenesis and immune cell infiltration and inflammatory factors as candidates for ERα-induced stroma-tumor signaling pathways. The results indicate that estrogen signaling in cervical cancer has dramatic differences from ERα+ breast cancers, and imply that estrogen signaling increasingly proceeds indirectly through ERα in tumor-associated stromal fibroblasts.

Pitfalls in the use of ocular ultrasound for evaluation of acute vision loss.

BACKGROUND: Retinal detachment is a true medical emergency. It is a time-critical, vision-threatening disease often first evaluated in the Emergency Department (ED). Diagnosis can be extremely challenging and confused with other ocular pathology. Several entities can mimic retinal detachment, including posterior vitreous detachment and vitreous hemorrhage. Ocular ultrasound can assist the emergency physician in evaluating intraocular pathology, and it is especially useful in situations where fundoscopic examination is technically difficult or impossible. Accurate and rapid diagnosis of retinal detachment can lead to urgent consultation and increase the likelihood of timely vision-sparing treatment. OBJECTIVES: This case demonstrates both the utility of ocular ultrasound in the accurate and timely diagnosis of retinal detachment and potential pitfalls in the evaluation of intraocular pathology in the ED. CASE REPORT: A 38-year-old woman presented with acute onset of bilateral visual loss that was concerning for retinal detachment. Rapid evaluation of the intraocular space was performed using bedside ocular ultrasound. Bedside ocular ultrasound correctly diagnosed retinal detachment in the right eye. Posterior vitreous detachment in the left eye was incorrectly diagnosed as retinal detachment. CONCLUSION: This case illustrates the importance of bedside ocular ultrasound and highlights some of the pitfalls that can occur when evaluating for retinal detachment. Following is a discussion regarding methods to distinguish retinal detachment from vitreous hemorrhage and posterior vitreous detachment.

Involvement of host cellular multivesicular body functions in hepatitis B virus budding.

Hepatitis B virus (HBV) is a major human pathogen that chronically infects approximately 350 million people, causing liver disease and liver cancer. HBV virions bud into an endoplasmic reticulum (ER)-associated intracellular compartment, but the mechanisms of HBV assembly, budding, and release remain poorly understood. Budding of retroviruses and some other enveloped RNA viruses from plasma membranes requires host functions involved in protein sorting into late endosomal multivesicular bodies (MVBs). To determine whether budding of DNA-containing HBV virions at intracellular membranes also involves MVB functions, we used immunofluorescence to show that, in human hepatoma cells, HBV envelope protein colocalizes with MVB proteins AIP1/ALIX and VPS4B. We also found that a dominant negative (DN) AIP1 mutant inhibited production and/or release of enveloped virions without significant effects on intracellular nucleocapsid formation, whereas DN VPS4B inhibited both nucleocapsid production and budding. By contrast, DN AIP1 and VPS4 had no effect on the efficiency of release of enveloped, nucleocapsid-lacking HBV subviral particles, which are produced in vast excess over virions, and dramatically increased the release of unenveloped, naked nucleocapsids by an apparently nonlytic route. Thus, host MVB functions are required for efficient budding and release of enveloped HBV virions and may be a valuable target for HBV control. Moreover, HBV enveloped virions, enveloped subviral particles, and unenveloped nucleocapsids are all released by distinct pathways with separate host factor requirements.