Susan Stone

Risk factors for injury to women from domestic violence

BACKGROUND Domestic violence is the most common cause of nonfatal injury to women in the United States. To identify risk factors for such injuries, we examined the socioeconomic and behavioral characteristics of women who were victims of domestic violence and the men who injured them. METHODS We conducted a case-control study at eight large, university-affiliated emergency departments. The 256 intentionally injured women had acute injuries resulting from a physical assault by a male partner. The 659 controls were women treated for other conditions in the emergency department. Information was collected with a standardized questionnaire; no information was obtained directly from the male partners. RESULTS The 256 intentionally injured women had a total of 434 contusions and abrasions, 89 lacerations, and 41 fractures and dislocations. In a multivariate analysis, the characteristics of the partners that were most closely associated with an increased risk of inflicting injury as a result of domestic violence were alcohol abuse (adjusted relative risk, 3.6; 95 percent confidence interval, 2.2 to 5.9); drug use (adjusted relative risk, 3.5; 95 percent confidence interval, 2.0 to 6.4); intermittent employment (adjusted relative risk, 3.1; 95 percent confidence interval, 1.1 to 8.8); recent unemployment (adjusted relative risk, 2.7; 95 percent confidence interval, 1.2 to 6.5); having less than a high-school-graduates education (adjusted relative risk, 2.5; 95 percent confidence interval, 1.4 to 4.4); and being a former husband, estranged husband, or former boyfriend (adjusted relative risk, 3.5; 95 percent confidence interval, 1.5 to 8.3). CONCLUSIONS Women at greatest risk for injury from domestic violence include those with male partners who abuse alcohol or use drugs, are unemployed or intermittently employed, have less than a high-school-graduates education, and are former husbands, estranged husbands, or former boyfriends of the women.

Dopamine modifies the balance of rod and cone inputs to horizontal cells of the Xenopus retina

Dopamine (greater than or equal to 2 microM) increased the cone input and suppressed the rod input to axon-bearing horizontal cells of the Xenopus retina. Dopamine (10 microM) also depolarized the horizontal cell by about 9 mV. The D2-dopamine antagonists spiperone and metoclopramide had the opposite action to dopamine, whereas the D1-dopamine antagonist SCH 23390 was without effect. None of the agents tested modified the light-evoked responses of rods.

Physiological and morphological properties of off- and on-center bipolar cells in the Xenopus retina: effects of glycine and GABA.

We studied the morphology and center-surround organization of Lucifer Yellow injected OFF- and ON-center bipolar cells in the light-adapted Xenopus retina and the effects of glycine and GABA on their cone-mediated light responses. In both classes of cell, prominent antagonistic surround responses up to 20 mV in amplitude could be evoked without first suppressing the center responses with steady illumination. An additional feature of the light-evoked bipolar cell response was a pronounced (up to -24 mV) delayed hyperpolarizing after potential (DHAP) which followed the depolarizing responses of both classes of bipolar cell. The morphological features of dye-injected bipolar cells conformed to the general idea of segregation of ON and OFF pathways in the inner and outer interplexiform layer, however, the morphology of axonal arborizations was different for both classes. OFF-center cells ramified symmetrically around the primary branchpoint, whereas ON-center cells had a strongly asymmetrical arrangement of their axonal tree. The center and surround responses were differentially sensitive to glycine and GABA. Glycine eliminated the antagonistic surround responses in both OFF and ON cells; the center responses were reduced to some extent but were not eliminated. In contrast, GABA affected the hyperpolarizing responses much more strongly than the depolarizing response components. That is, the amplitude of the center response in the OFF cell and the surround response in the ON cell was reduced 80-90% during exposure to GABA, whereas the surround and center depolarizations of OFF and ON cells, respectively, were reduced only 0-10%. Our findings implicate a role for GABAergic and glycinergic pathways in the center-surround organization of bipolar cells in Xenopus retina. In addition, the results suggest that the pathways mediating center-surround antagonism may be different in OFF-bipolar cells vs. ON-bipolar cells.

I want to be taking my own last breath: patients' reflections on illness when presenting to the emergency department at the end of life.

OBJECTIVE To understand perceptions regarding their illness of patients who present to the Emergency Department at the end of life. METHODS Semistructured one-on-one interviews were performed with a convenience sample of seriously ill, Emergency Department (ED) patients with advanced illness presenting to an urban, public hospital. A bilingual Latina health promoter used a predetermined discussion guide to conduct all interviews. Non-English- or Non-Spanish-speaking patients and those with uncontrolled symptoms or cognitive deficits were excluded. All interviews were recorded and transcribed, and grounded theory methodology was used to analyze the results. RESULTS Thirteen patients with advanced illness participated, 8 of whom were Spanish-speaking only. Because of difficulty accessing care and financial concerns, patients with advanced illness present to EDs when their pain or other symptoms are out of control. The majority derive great comfort and strength from their faith in God, who they believe determines their fate. Most listed spending time with family, and not being a burden, as most important at the end of life, and many expressed a preference to die at home surrounded by loved ones. Almost none had spoken to physicians about their care preferences. CONCLUSIONS Patients with advanced illness present to the ED of a safety net hospital when symptoms are out of control. They have many financial concerns, want to spend their remaining days with family, and do not want to be a burden. Most derive immense comfort from faith in God, but do not feel they have control over their own fate.

Rod and cone inputs to bipolar and horizontal cells of theXenopus retina

This report summarizes some recent studies of the Xenopus retina in which intracellular recordings were made from photoreceptors, horizontal and bipolar cells. The studied cells were identified by injection of Lucifer yellow. Rod spectral sensitivity functions conformed to the density spectrum of a 524 nm pigment, those of cones to that of a 612 nm pigment. Horizontal cell responses reflected both these classes of photoreceptor input. Rod input evoked a slow waveform, with Vmax less than or equal to 18 mV, cone input a faster waveform with Vmax = 30-40 mV. In the mesopic state the horizontal response reflected both waveforms. Rod and cone inputs to the horizontal cells appeared not to act independently, in that a steady weak green background greatly enhanced the response to a superimposed red flash, but not the reverse. A third photoreceptor type (blue-sensitive rod, Y lambda max = 445 nm) provided input to a chromatic bipolar cell which was hyperpolarized by blue light and depolarized by red light. Such chromatic bipolars had broad areas of spatial integration and lacked center-surround organization.

Emergency department research in palliative care: challenges in recruitment.

Dear Editor: Measuring the health outcomes of studies involving seriously ill patients in acute care settings can be challenging. Recruiting patients who are severely ill and under physical and emotional distress is often complicated by rapid changes in clinical status and high acuity. The difficulty encountered by palliative care researchers due to issues of nonenrollment is real and leads to biased studies that exclude the exact group of patients we wish to evaluate. Emergency departments (EDs) can provide an ideal opportunity to study patients with significant palliative care needs. Early intervention in the ED can lead to more timely provision of care, including direct referral to hospice, and can be cost effective due to reduced hospital length of stay. While this group of patients is important to study, there are as yet no published randomized controlled trials in the ED that measure outcomes of palliative care interventions. We recently completed enrollment for a prospective, randomized trial of an ED-based palliative care intervention (EDHELP), which compared an early palliative care consult (within 4 hours of consult initiation) to standard care (patients typically seen by the palliative care team at the discretion of the inpatient team or after 8 hours). Outcome data will be presented in a future article. This letter discusses the enrollment issues of this study. The study was conducted in the ED of a large public hospital serving a largely Latino population. Bilingual and bicultural staff recruited patients in the ED. We block-randomized by week as to whether a patient received an early palliative care consult versus standard care. The consent could only be completed by the patient, not by surrogates. Palliative care services were explained to the patient during the consent process. The study design and procedures were approved by the study site’s Institutional Review Board. Approximately 390 patients were offered participation in the study. The majority of patients had cancer (64%, n1⁄4 251) followed by organ failure (23%, n1⁄4 88). Only approximately half (49%, n1⁄4 193) passed a cognitive screen, spoke Spanish or English, and agreed to participate. The most common reason for not enrolling was the inability to complete the interview due to acuity (38%, n1⁄4 74). One quarter of the patients who did not enroll stated concerns about signing a consent form. We also lost 16 patients because of transfer to home or the inpatient bed prior to the study completion. Cultural and socioeconomic factors may have influenced recruitment. A study among a predominantly African American population found a ‘‘recruitment triangle’’ that influences whether patients will enroll in a study. The triangle arms include the patient, family members and friends, and treatment team (typically the primary physician). The triangle was pivotal in gaining patient trust. Among Latinos, family is also highly valued, and family member inclusion in the consent process would have likely increased recruitment. Ling et al. recommend that during enrollment in palliative care trials, investigators should not use the same methods as a trial for a new cancer therapeutic agent—they should reduce the requirements for enrollment and create realistic entry criteria. Similar to our study, Ling et al. found the following common reasons given for unwillingness to participate: (1) deterioration in condition; (2) transfer to another unit; (3) inability to give consent; or (4) family objection. Many of our study patients preferred to have family present, could not make the decision alone, or had family object to consent. Our nonenrolled study patients may have had an unclear understanding of what palliative care services can offer. While we tailored the consent to provide information about the service, there may have been patient concerns that were not addressed. In prospective trials, it is not always clear that a fully informed evaluation of the pros and cons of participation and nonparticipation has taken place. Research trials to study the impact of palliative care into the ED are important. When conducting such trials, investigators must consider barriers to recruitment and be creative and attuned to the specific needs of the targeted population. Enrollment of patients in future studies may require Institutional Review Boards to accept presumed or emergency consents that is often are being used in resuscitation research. In order to answer key palliative care questions and in the end improve care for patients at the end of life, such approaches to enrollment should be advocated. Ultimately, this group of patients with high acuity in need of palliative care deserve patients in need of palliative care deserve further investigation; however, investigators must be aware of the challenges in recruitment.

Perspectives From the Other Side: A Physician and Cancer Survivor

ASCO has made great strides to integrate palliative care into the comprehensive care model. However, much work remains to ensure that all patients, whether receiving curative or palliative therapy, have a good quality of life.

Critical Conversations When the Bedside Clinician Calls for Clinical Ethics

VignetteBackground: Sharon is a 56-year-old woman who has been complaining of bloating and discomfort for years. While descending steps from her hillside home, she recently fell and fractured her pelvis. A CT of the pelvis revealed a large ovarian mass with smaller masses in the peritoneum, and studies of the chest and upper abdomen revealed masses in the liver and lung. A recent biopsy confirmed poorly differentiated cells. She was diagnosed with metastatic ovarian carcinoma and managed conservatively for the pelvic fracture. Until last month Sharon ran a preschool, but she has been homebound for weeks.Presentation: Now, a month after the fracture, Sharon has developed increasing shortness of breath and has been admitted to the hospital with fever and pulmonary infiltrates bilaterally. She appears weak and delirious and has a raspy cough and signs on examination of extensive lung consolidation. She has lost a substantial amount of weight since last month. She is receiving high-flow oxygen 100% in the ICU...