Expanded and independent validation of the Movement Disorder Society–Unified Parkinson’s Disease Rating Scale (MDS-UPDRS)

The Movement Disorder Society-UPDRS (MDS-UPDRS) was published in 2008, showing satisfactory clinimetric results and has been proposed as the official benchmark scale for Parkinson’s disease. The present study, based on the official MDS-UPDRS Spanish version, performed the first independent testing of the scale and adds information on its clinimetric properties. The cross-culturally adapted MDS-UPDRS Spanish version showed a comparative fit index ≥0.90 for each part (I–IV) relative to the English-language version and was accepted as the Official MDS-UPDRS Spanish version. Data from this scale, applied with other assessments to Spanish-speaking Parkinson’s disease patients in five countries, were analyzed for an independent and complementary clinimetric evaluation. In total, 435 patients were included. Missing data were negligible and moderate floor effect (30 %) was found for Part IV. Cronbach’s α index ranged between 0.79 and 0.93 and only five items did not reach the 0.30 threshold value of item-total correlation. Test–retest reliability was adequate with only two sub-scores of the item 3.17, Rest tremor amplitude, reaching κ values lower than 0.60. The intraclass correlation coefficient was higher than 0.85 for the total score of each part. Correlation of the MDS-UPDRS parts with other measures for related constructs was high (≥0.60) and the standard error of measurement lower than one-third baseline standard deviation for all subscales. Results confirm those of the original study and add information on scale reliability, construct validity, and precision. The MDS-UPDRS Spanish version shows satisfactory clinimetric characteristics.     

Liability of Emergency Physicians for Studies Ordered in the Emergency Department: Court Cases and Legal Defenses

Background: Laboratory tests are frequently ordered in the Emergency Department (ED), with results returning at a later time. Emergency physicians (EPs) are frequently held liable when the test results are not followed-up. Methods: Recent legal malpractice cases are presented to provide examples of the medical-legal risks encountered when poor patient outcomes occur because the results of laboratory tests and other studies done in the ED are not followed-up and communicated to the patient. Discussion: Emergency physicians are obligated to follow-up with patients when the results of laboratory and radiographic studies ordered in the ED are returned at a later time, and EPs are liable for any poor outcome if there is no follow-up. Appropriate follow-up mechanisms must be in place to improve patient outcomes and reduce the risk for the physician. Knowledge of the legal concepts of contributory negligence and comparative fault allows EPs to place themselves in an optimal position for a legal defense if a challenge is raised. Conclusion: It is imperative that abnormal results of tests done for ED evaluation and orders must be properly noted and followed-up. Optimal communication and relay of information to both the patient and the primary physician will reduce physician liability and enhance patient outcomes.     

An Independent Investigation Into the Psychometric Properties of the Adult Scale of Hostility and Aggression (A-SHARP)

Background: The Adult Scale of Hostility and Aggression (A-SHARP) rating scale assesses the frequency/severity (problem scale) and the reactive-proactive motivation (provocation scale) of aggressive behaviors in adults with intellectual disabilities (ID). Items are assigned to five subscales (Verbal Aggression, Physical Aggression, Hostile Affect, Covert Aggression, and Bullying). Although psychometric properties reported by the scale’s developers were very good, we wanted to corroborate them independently. We were also interested in whether the reactive-proactive distinction of aggressive behavior is related to a behavioral/functional classification. Method: Staff at a day-treatment program for adults with ID completed ratings for 155 clients using the A-SHARP, the Behavior Problems Inventory-01 (BPI-01), and the Questions about Behavioral Function (QABF). Results: Internal consistency was found to be excellent, and the A-SHARP Physical Aggression subscale had good congruent and clinical validity. Confirmatory factor analysis showed sufficient evidence toward the factorial validity of the A-SHARP’s problem scale. The reactive-proactive classification of aggressive behavior motivation by the A-SHARP’s provocation scale was independent of the functional classification. Conclusions: The A-SHARP is a useful addition to a small number of existing instruments for assessing aggressive behavior in adults with ID, especially its problem scale. We discuss how the A-SHARP provocation scales might provide therapy-relevant information. Empirical evidence for the clinical utility of the A-SHARP provocation scale will have to be established by future research.     

Ultraviolet B radiation regulates cysteine‐rich protein 1 in human keratinocytes

Background: Cysteine‐rich protein 1 (CRP1) is a growth‐inhibitory cytoskeletal protein that is induced by ultraviolet (UV) C radiation radiation in fibroblasts. Our aim was to investigate the effects of UV radiation on CRP1 in keratinocytes, the main cell type subjected to UV radiation in the human body. Methods: The effects of physiologically relevant doses of UVB radiation on CRP1 protein levels were studied in cultured primary keratinocytes and transformed cell lines (HaCaT, A‐431) by immunoblotting. UVB‐induced keratinocyte apoptosis was assessed by flow cytometry and monitoring caspase activity. Expression of CRP1 in human skin in vivo was studied by immunohistochemistry in samples of normal skin, actinic keratosis (AK) representing UV‐damaged skin and squamous cell carcinoma (SCC), a UV‐induced skin cancer. Results: CRP1 expression increased by UVB radiation in primary but not in immortalized keratinocytes. Upon high, apoptosis‐inducing doses of UV radiation, CRP1 was cleaved in a caspase‐dependent manner. In normal skin, CRP1 was expressed in smooth muscle cells, vasculature, sweat glands, sebaceous glands and hair root sheath, but very little CRP1 was present in keratinocytes. CRP1 expression was elevated in basal cells in AK but not in SCC. Conclusion: CRP1 expression is regulated by UVB in human keratinocytes, suggesting a role for CRP1 in the phototoxic responses of human skin.     

Teachers as Learners: Developing Professionalism Feedback Skills via Observed Structured Teaching Encounters

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Southern Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of 4 experts who shared their thoughts stimulated by the study. These thoughts explore the value of the Observed Structured Teaching Encounter in providing structured opportunities for medical students to engage with the complexities of providing peer feedback on professionalism.     

Effect of Establishing Guidelines on Appropriate Urinary Catheter Placement

Objectives: Avoiding placement of unnecessary urinary catheters (UCs) in the emergency department (ED) affects UC utilization during hospitalization. The authors sought to evaluate the effect of establishing institutional guidelines for appropriate UC placement coupled with emergency physician (EP) education on UC utilization. Methods: Urinary catheter utilization was measured before and after the establishment of guidelines and EP education. Data collected included the presence of a UC on ED arrival, placement of a UC in the ED, documentation of a physician order for UC placement, reasons for placement, and compliance with the guidelines. Chi‐square analyses were used to study the association between pre‐ and postintervention time periods and catheter use. Results: A total of 377 (15%) patients had UCs; only 151 (47%) UCs initially placed in the ED had a physician order documented. UC placement was appropriately indicated in 75.5% of patients with a documented physician order, but in only 52% of cases without a documented physician order (p < 0.001). The physician intervention was associated with an overall reduction in UC utilization from 16.4% to 13% (p = 0.018). Physicians ordered 40% fewer UCs postintervention compared to preintervention. Preintervention, a physician order for UC placement was found indicated in 72.6% patients, compared to 82.2% patients with UC placed postintervention (p = 0.21). Conclusions: Establishing guidelines for UC placement and physician education in the ED were associated with a marked reduction in utilization. However, addressing appropriate UC utilization may require evaluating other factors such as nursing influence on utilization. ACADEMIC EMERGENCY MEDICINE 2010; 17:337–340 © 2010 by the Society for Academic Emergency Medicine