A Retrospective Analysis of Adverse Events in Hyperbaric Oxygen Therapy (2012-2015): Lessons Learned From 1.5 Million Treatments.

OBJECTIVE: To describe the distribution and occurrence of adverse events recorded during hyperbaric oxygen (HBO) therapy from 2012 to 2015. In this analysis, events are defined as otic/sinus barotrauma, confinement anxiety, hypoglycemia, oxygen toxicity, pneumothorax, seizure, and shortness of breath. DATA AND ANALYSIS: The data for the analysis were drawn from a proprietary electronic health data system that contained information on 1,529,859 hyperbaric treatments administered during 53,371 treatment courses from 2012 to 2015 in outpatient wound care centers across the United States managed by Healogics, Inc, Jacksonville, Florida. RESULTS: Of the 1.5 million treatments included in the analysis, 0.68% were associated with an adverse event. Barotrauma and confinement anxiety were the most frequently reported events. Medically severe events were extremely uncommon, with fewer than 0.05 instances of oxygen toxicity per 1000 treatments and only 1 confirmed case of pneumothorax. CONCLUSIONS: Results indicate that the occurrence of adverse events associated with HBO therapy is infrequent and typically not serious. The findings of this study suggest that when administered according to the appropriate therapeutic protocols HBO therapy is a safe and low-risk intervention.

Doxycycline as a modulator of inflammation in chronic wounds.

 Doxycycline is a semisynthetic, chemically modified tetracycline compound that is rapidly absorbed and exerts biological effects independent of its antimicrobial activity. One such effect includes the inhibition of matrix metalloproteinases. Doxycycline has a long history as a collagenase inhibitor. This article will describe its mode of action and review its effectiveness in significantly reducing inflammation and elevated levels of proinflammatory cytokines within chronic wounds. .

The G-protein-coupled receptor 40 family (GPR40-GPR43) and its role in nutrient sensing.

Recent deorphanization efforts have paired the G-protein-coupled receptors GPR40, GPR41 and GPR43 with fatty acids as endogenous ligands. While carboxylic acids have been historically known to serve as fuel sources and biomarkers of disease, these studies demonstrate that fatty acids can act as signalling molecules at the cell-surface level. This receptor subfamily shares approx. 30% identity among members, with some limited cross-over between ligand activities. Generalized expression patterns within the pancreatic beta-cell, adipose depots and the gastrointestinal tract infer involvement in energy source recognition, absorption, storage and/or metabolism. GPR40, activated by medium and long-chain fatty acids, has been shown to potentiate insulin secretion at the beta-cell, and has been hypothesized to participate in the detrimental effects of chronic fatty acid exposure on beta-cell function. GPR41 and GPR43 have been reported to stimulate leptin release and adipogenesis respectively via activation by short-chain fatty acids. These common themes implicate GPR40, GPR41 and GPR43 in playing significant roles in metabolic diseases, such as diabetes, obesity and the metabolic syndrome.

A statewide analysis of level I and II trauma centers for patients with major injuries.

BACKGROUND: This study examines statewide outcomes and resource use in Level I and II trauma centers for patients with major injuries. METHODS: This study analyzed trauma registry data on patients admitted to North Carolina Level I and II trauma centers from January 1995 to December 1996 with one of four major injuries: thoracic aortic disruption, liver injury, pelvic fracture, or pulmonary contusion. RESULTS: There were 59 thoracic aortic disruptions, 109 liver injuries, 153 pelvic fractures, and 962 pulmonary contusions identified among 26,030 admissions. Case fatality was not significantly different (Level I, 16.8%; Level II, 14.9%). Hospital charges were significantly higher in Level I centers (Level I, $47,366; Level II, $35,490), but this difference was confined to transferred patients. Controlling for Revised Trauma Score, Injury Severity Score, age, gender, and race, multivariable regression confirmed findings regarding hospital charges, and multiple logistic regression confirmed findings regarding case fatality. CONCLUSION: Case fatality was similar in Level I and Level II trauma centers in North Carolina, and hospital charges were comparable in patients with comparable injuries not requiring transfer. This suggests that patients with major injuries may be optimally cared for in both Level I and Level II trauma centers.

Synthetic membrane neo-pericardium facilitates total artificial heart explantation.

BACKGROUND: In the past, explantation of the Cardio West total artificial heart (TAH) has been technically challenging because of the presence of dense adhesions and extremely thickened pericardium. To prevent this, we constructed a synthetic neo-pericardium in 14 patients. METHODS: Using expanded polytetrafluoroethylene (e-PTFE) membrane, we constructed a pericardium within the pericardium, or "neo-pericardium," completely covering the Cardio West TAH separating the native atria from the native pericardium, and wrapping the ascending aorta from the outflow conduit distally for about 5 to 7 cm. RESULTS: Of the 14 patients, 9 were transplanted and could be evaluated, 3 died on device support, and 2 are currently on device support. In each case, we attained faster (by 25 minutes) and easier reentry through the sternum. Surgical planes around the aorta, over the right and left atria, and throughout the pericardial space became apparent immediately after e-PTFE membrane removal. The pericardium and related tissues although slightly thickened (<2 mm) were pliable compared with our previous 36 patients, with very thick adherent pericardium over the device and native atria. CONCLUSIONS: The plastic materials forming the ventricular housing and drivelines of the Cardio West TAH and the Dacron outflow conduits have in the past caused profound local inflammatory reactions, resulting in extremely dense adhesions and thickened adherent pericardium. Using e-PTFE membrane to fashion a complete neo-pericardium and to wrap the ascending aorta at the time of Cardio West implantation dramatically reduces adhesions and pericardial thickening and facilitates explantation.

Cytotoxicity of 2-ethenyl-2,3-dihydrophthalazine-1,4-diones in murine and human tumor cultured cells.

2-Etheny1-2,3-dihydrophthalazine-1,4-diones were successfully synthesized and proved to be effective cytotoxic agents against the growth of suspended murine and human leukemias and lymphomas. Selected compounds were also active in human HeLa uterine carcinoma, suspended effusion breast MCF-7 and glioma HS683 screens. These agents suppressed P388 lymphocytic leukemia DNA synthesis after 60 min at 100 microM. Their target appeared to be the de novo synthesis pathway with significant inhibition of the activities of both regulatory enzymes of the pathway, i.e. PRPP-amide transferase and IMP dehydrogenase resulting in a reduction in the d[NTP] pool levels for DNA incorporation. The compounds did not affect de novo pyrimidine synthesis and its regulatory enzymes. Very minor reduction by the agents was noted for the nucleoside kinases and the DNA and RNA polymerase activities within 60 min. DNA was not a target of the agents in that there was no alkylation of the nucleotide bases, intercalation between base pairs or cross-linking of the DNA strands; however, the agents did cause P388 DNA strand scission after 24 h at 100 microM.

Severity, manifestations, and consequences of violence among pregnant adolescents.

PURPOSE: To examine the severity, manifestations, and consequences of prenatal violence among adolescent and adult participants in a county health department prenatal care coordination program. METHODS: The prospective cohort study design included all Medicaid-eligible program participants from 1994 to 1996. Care coordinators screened participants for prenatal violence using a validated, systematic violence assessment protocol at three times during pregnancy. This protocol was linked with prenatal care and hospital delivery records to document pregnancy outcomes. The main outcome variables were low birth weight (<2500 g) and preterm delivery (before 37 weeks' gestation). RESULTS: Among teens, 16.1% reported prenatal violence, including 9.4% who reported severe violence such as hitting, kicking, or stabbing. Among adults, 11.6% reported prenatal violence, including 4.8% who reported severe violence. Teens were more likely than adults to report abdominal trauma (56% vs. 22%) and violence perpetrated by a relative (23% vs. 5%). Teens who reported severe prenatal violence were more likely to report alcohol use. They were significantly more likely to deliver preterm than teens who reported "other" or "no" prenatal violence (odds ratio 3.5, 95% confidence interval 1.1-10.8) when adjusting for race, adequacy of prenatal care, prior preterm delivery, and alcohol use. For adults, the relationship between prenatal violence and preterm delivery was not statistically significant. The relationship between prenatal violence and low birth weight was not significant for either age cohort. CONCLUSIONS: Prenatal violence was a significant risk factor for preterm birth in this population, especially among teens.

Preterm delivery and the severity of violence during pregnancy.

OBJECTIVE: To determine the severity and consequences of physical violence during pregnancy among participants in a health department prenatal care coordination program. STUDY DESIGN: The prospective cohort study included all program participants from 1994 to 1996. Care coordinators screened participants for physical violence during pregnancy using a validated, systematic assessment protocol three times during prenatal care. The protocol was linked with prenatal records, delivery records and infant records to document complications and infant outcomes. Multiple logistic regression was used to assess the relationship between severe physical violence during pregnancy and pregnancy outcome while controlling for confounding factors. RESULTS: Among the 550 participants, 13.5% reported violence during pregnancy; it included 6.7% severe violence (hitting, kicking, injury with a weapon and abdominal injury) and 6.7% moderate violence (threats, slapping, shoving and sexual abuse). Severe physical prenatal violence was significantly associated with spontaneous preterm labor, preterm delivery, very preterm delivery, very low birth weight, preterm/low birth weight, mean birth weight, mean newborn hospital charges, five-minute Apgar < 7, neonatal intensive care unit admission, and fetal or neonatal death. Body site injured, timing of violence and number of violent incidents were significant factors associated with violence during pregnancy and preterm delivery. CONCLUSION: Because severe physical violence during pregnancy was a significant problem in this population, intervention programs are needed to reduce prenatal violence and its consequences.

Who gets screened during pregnancy for partner violence?

CONTEXT: Despite recommendations to screen prenatal care patients for partner violence, the prevalence of such screening is unknown. OBJECTIVES: To estimate the statewide prevalence of partner violence screening during prenatal care among a representative sample of North Carolina women with newborns and to compare women screened for partner violence with women not screened. DESIGN, SETTING, AND PARTICIPANTS: This investigation examines data gathered through the North Carolina Pregnancy Risk Assessment Monitoring System, a random sample of more than 2600 recently postpartum women who were delivered of newborns between July 1997 and December 1998. MAIN OUTCOME MEASURES: Self-reports of violence, health service factors, and sociodemographic characteristics. ANALYSIS: The prevalence of screening was computed, and odds ratios and 95% confidence intervals were used to examine bivariate and multivariable associations between being screened for partner violence and other factors. RESULTS: Thirty-seven percent of women reported being screened for partner violence during prenatal care. Logistic regression analysis found that women were more likely to be screened if they received prenatal care from (1) a public provider paid by a public source; (2) a private provider paid by a public source; or (3) a public provider paid by a private source. CONCLUSIONS: These findings suggest that the majority of prenatal care patients in North Carolina are not screened for partner violence. Screening appears to be most highly associated with whether a woman is a patient in the public sector or the private sector, and with the source of payment for prenatal care. Arch Fam Med. 2000;9:1093-1099

Carotid endarterectomy reoperations in a regional medical center.

Large, randomized prospective clinical trials have not addressed the safety of reoperation for recurrent carotid disease. Our purpose was to determine whether outcomes for carotid endarterectomy for recurrent disease were different from those for primary or contralateral carotid endarterectomy. We reviewed all carotid endarterectomies done in our regional medical center hospital from 1979 through 1997. We analyzed 1656 primary procedures, 377 contralateral carotid procedures, and 63 reoperations. Operation for recurrent disease was done in 3 per cent of those having primary operations. Patients in the three groups did not differ significantly with regard to age, race, or sex. Seventy per cent of patients were symptomatic with transient ischemic attacks, amaurosis, and reversible ischemic neurological deficit being most prominent. There were no deaths and three strokes in the reoperation group for a combined stroke and death rate of 4.8 per cent. This was not significantly different from that of 3.2 per cent for the stroke and death rate for the primary group and 3.5 per cent for the contralateral group. Carotid endarterectomy is a safe treatment for recurrent carotid artery disease.

Carotid endarterectomy in the community hospital in patients age 80 and older.

OBJECTIVE: To determine whether the rates of death and complications of carotid endarterectomy (CE) were different in the octogenarian population than in patients younger than age 80. SUMMARY BACKGROUND DATA: The utility of CE depends on the ability of the surgeon and hospital to attain low rates of death and complications, including all subgroups of the patient population. In the past 30 years, the number of people age 85 and older has increased 274%. METHODS: Detailed chart review was carried out on all CE procedures done from 1979 through 1998. Descriptive demographic data, risk factors, surgical details, length of stay, deaths, and complications were recorded. RESULTS: A total of 2,398 CEs were performed in 1,970 patients; 2,180 procedures were performed in 1,783 patients younger than 80, and 218 CEs were performed in 187 patients age 80 and older. Sixty-five percent of the octogenarians and 67% of patients younger than age 80 had neurologic symptoms. Among asymptomatic patients, 89% had stenosis of 75% or more. There were 62 strokes in the 2,180 procedures in the younger group, for a stroke rate of 2.8%, and 7 strokes in the 218 procedures in the older group, for a stroke rate of 3.2%. The death rates were 0.9% for the octogenarians and 1.4% for the younger group. CONCLUSIONS: Carotid endarterectomy can be safely performed in a community hospital in patients age 80 and older. Outcomes in octogenarians were not significantly different than those of younger patients and were within the range required for CE to be considered beneficial in the prevention of stroke.

An analysis of trends, perceptions, and use patterns of electronic medical records among US family practice residency programs.

BACKGROUND AND OBJECTIVES: This study intended to quantify electronic medical record (EMR) use in family practice residencies, associate program characteristics with EMR use, and identify perceptions and issues about the use of EMRs. METHODS: A survey was mailed to all 454 US family practice residency programs, with a 72% response rate. The survey, which was pretested and revised, was designed to identify benefits, problems, perceptions, and trends regarding the use of EMRs. RESULTS: Fifty-five of 329 programs (17%) were using an EMR, while 10 (3%) had used an EMR but discontinued. Programs in the South reported the highest EMR use (21%, 21/99), and those in the North Central region reported the lowest use (11%, 11/102). EMR use was highest in university settings (19%, 15/81), programs offering fellowships (26%, 24/92), new programs (36%, 18/48), and programs that require research (22%, 20/91). Of the 329 programs that responded, 43% (143 programs) reported having information systems (IS) committees. Of the 55 programs currently using EMRs, 78% had at least one full-time equivalent IS technician. Of programs that discontinued use, software inadequacy was the most frequently cited reason (40%, 4/10). Programs that had never used EMR systems (n = 264) were more likely than those that had used EMRs (n = 65) to favorably perceive EMRs with respect to 1) meeting program requirements (44% versus 34%), 2) documenting improved patient care (65% versus 43%), 3) providing a reliable research database (94% versus 55%), and 4) documenting resident experience (92% versus 53%). Of the 264 (80%) programs that had never used an EMR, 172 (65%) plan to implement one. CONCLUSIONS: EMR use is low among US family practice residency programs, but some success in implementation of EMRs has been achieved. Based on the responses to this survey, use will likely increase from 55 of 329 programs (17%) to 153 of 329 (47%) by 2000.

Laparoscopic cholecystectomy in octogenarians.

Performance of laparoscopic cholecystectomy (LC) is increasing, and patients age 80 and over comprise an increasingly larger proportion of the LC population. This study documents that the increase is accompanied by safe outcome in this patient population. However, the evidence also suggests that cholelithiasis appears to have been a neglected condition in this age group. The prevalence of nonelective procedures, the conversion rate to an open operation, more intraoperative complications, and the percentage having evidence of common bile duct stone passage all support this assertion. With the technology of LC, we are now appropriately addressing the problem with a treatment that allows less surgical trauma to the patient and shorter recovery time. Same-day LC surgery for the octogenarian appears to be very safe and would justify a decision to perform earlier LC in these patients. Surgery done before the appearance of comorbid conditions that increase the surgical and anesthetic risks may result in improved outcomes for the elderly at lower cost. Even when necessary in the already hospitalized patient, LC can be accomplished with morbidity and mortality comparable to those of elective abdominal procedures in younger populations.

DRG reimbursement: geriatric hip fractures in the community hospital trauma center.

BACKGROUND: The purpose of this paper was to determine whether Medicare reimbursement for hip fracture reaches cost in geriatric patients. METHODS: We conducted a retrospective review using the hospital trauma registry. Demographics, operations, length of stay, clinical outcome, discharge disposition, hospital charges, and hospital costs were reviewed and compared with diagnosis-related group (DRG) reimbursement. RESULTS: The study included 153 Medicare patients. Mortality was 3.9%, 71% were discharged to a nursing home or rehabilitation unit, and 25% went directly home. DRG reimbursement constituted 58% of charges. Compared with costs, the DRG amount represented a mean loss of nearly $1,000 per patient. CONCLUSIONS: DRG reimbursement undercompensates the community hospital trauma center for treating a common malady among the geriatric population. A population shift toward the elderly, decreasing Medicare remuneration, and the advance of managed care will make correct identification and control of costs extremely important for the hospital caring for hip fractures in the geriatric population.

Breast conservation surgery for breast cancer at a regional medical center.

BACKGROUND: This study examined trends in breast conservation surgery (BCS) at our hospital and factors associated with BCS. METHODS: We retrospectively reviewed breast cancer surgeries in patients eligible for BCS (size <4 cm, N0, N1) from 1990 through 1996 (n = 634). We calculated the yearly prevalence of BCS and used multiple logistic regression (MLR) to determine tumor, patient, and surgeon factors associated with BCS. RESULTS: BCS increased from 17% in 1990 to 41% in 1996. Women with T1a and T1b tumors were 3.8 and 2.0 times, respectively, as likely to have BCS compared with those who had T2 tumors. Other factors associated with BCS included nonpalpable tumors, age <50, Medicare, Medicaid, or self-pay patients, and women whose surgeons graduated since 1961, with odds ratios of 1.8, 1.9, 2.4, and 2.3, respectively. CONCLUSION: Women with small, nonpalpable tumors, age <50, without private insurance, operated on by younger surgeons were more likely to receive BCS.

Cholecystectomy in patients aged 80 and older.

BACKGROUND: We assessed whether the increase in performance of laparoscopic cholecystectomy has affected patients aged 80 and older and if outcomes of a laparoscopic approach in this population would show improvement over those for open surgery. METHODS: We analyzed an 11-state discharge database obtained from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Release 1 contains a 20% sample of United States hospitals for the period 1988 to 1992. Diagnosis-related group (DRG) codes 197 and 198 were searched, and demographics, type of surgery, and outcome measures were analyzed. RESULTS: In 5 years, 350,451 patients underwent cholecystectomy with the DRG codes listed. Of those, 18,500 patients were aged 80 to 105. The total number of cholecystectomies increased each year. Performance of laparoscopic cholecystectomy rose rapidly and that of open cholecystectomy decreased. Overall mortality with laparoscopic cholecystectomy was 1.8%, was lower than that of open cholecystectomy, was lower in women, and decreased with time. CONCLUSIONS: Patients aged 80 and older have participated in the increased performance of cholecystectomy and the switch to laparoscopic cholecystectomy. This has a low mortality, low length of stay, and higher proportion of patients being discharged to home compared with patients having open cholecystectomy.

A statewide, hospital-based analysis of frequency and outcomes in carotid endarterectomy.

BACKGROUND: For more than 40 years carotid endarterectomy (CE) has been used in the treatment of extracranial carotid disease for the prevention of stroke. Recent prospective clinical trials have confirmed the benefit of CE for both symptomatic and asymptomatic patients. Our purpose was to examine statewide trends in the numbers of CE over a 6-year time period and to evaluate outcomes. METHODS: Using data from the North Carolina Medical Database Commission (NCMDC) all CE procedures from 1988 to 1993 were identified. Numbers of CE were compared with the population and hospital admissions. Variables of length of stay, hospital charges, discharge disposition, and occurrence of stroke and death were analyzed. RESULTS: A total of 11,973 CE were performed in 6 years. Compared by admissions, population, and the proportion of elderly, the number of CE increased yearly. The stroke rate was 1.7% and the death rate 1.2% for an overall in-hospital stroke plus mortality rate of only 2.7%. CONCLUSIONS: From a diverse group of hospitals and a large number of surgeons and patients, this hospital-based study documents the acceptance and safety of CE in the treatment of extracranial carotid disease.

Improving detection of violence among pregnant adolescents.

PURPOSE: The purpose of this study was to determine whether a systematic assessment protocol could increase reporting of violence among pregnant adolescents compared with a routine prenatal assessment. This study also sought to examine issues related to violence assessment among maternity care coordinators. METHODS: The Maternity Care Coordination (MCC) program in a health department prenatal clinic in North Carolina routinely screened all clients for violence at their first visit. This assessment was not standardized. In 1994, the MCC program implemented a systematic violence assessment protocol for all adolescents (n = 117). The protocol assessed violence at three points during pregnancy by asking one direct question: "Have you been hit, slapped, kicked, or hurt during this pregnancy?" To examine the effectiveness of the system, we retrospectively reviewed the 1993 MCC records in which the coordinators routinely screened clients for violence (n = 129). To examine issues related to screening, we conducted in-depth interviews with the maternity care coordinators. RESULTS: The routine pre-intervention assessment indicated that 5.4% of adolescents 12-19 years of age reported prenatal violence. The systematic assessment protocol resulted in a significant increase in reported violence from 5.4% to 16.2% (odds ratio = 2.9, 95% confidence interval = 1.6, 5.6, adjusted for race). Maternity care coordinators identified five factors related to increased reporting using the standardized protocol: (a) written protocol and data collection form; (b) asking direct, specific questions; (c) not labeling the victim; (d) not naming the perpetrator; and (e) conducting multiple assessments. CONCLUSIONS: Multiple, direct, systematic assessments throughout prenatal care resulted in increased reporting of prenatal violence among adolescents compared to single, routine, nonstructured assessments.

PIP: This study tested the hypothesis that use of a direct, systematic assessment protocol applied throughout the course of prenatal care rather than a one-time, nonstructured, routine assessment would increase the reporting of prenatal violence among adolescents. Data from a retrospective assessment of the records of all 142 adolescents aged 12-19 years enrolled during 1993 (when the assessment was nonstructured) in the Maternity Care Coordination program of a health department prenatal clinic in North Carolina were compared to data from all 130 adolescents enrolled during 1994-95 when the systematic protocol was in place. The 13 adolescents with repeat pregnancies were excluded from analysis. The assessment protocol asked the direct question "Have you been hit, slapped, kicked, or hurt?" at three points during pregnancy. It was found that the standardized assessment protocol resulted in almost twice as many reports of violence at initial assessment, but this result was not statistically significant. However, multiple assessments using the systematic protocol increased reporting of prenatal violence significantly and consistently documented the perpetrator of the violence (68% partners, 14% parents, 9% siblings, and 9% friends). In-depth interviews with the seven maternity care coordinators confirmed that the new intervention tool was useful and effective because it used a written protocol and data collection form; asked direct, specific questions; did not label the victim; did not require the perpetrator's name; and involved multiple assessments.

Management outcomes in splenic injury: a statewide trauma center review.

OBJECTIVE: Clinical pathways now highlight both observation and operation as acceptable initial therapeutic options for the management of patients with splenic injury. The purpose of this study was to evaluate treatment trends for splenic injury in all North Carolina trauma centers over a 6-year period. METHODS: Splenic injuries in adults over a 6-year period (January 1988-December 1993) were identified in the North Carolina Trauma Registry using ICD-9-CM codes. Patients were divided into four groups by method of management: 1) no spleen operation, 2) splenectomy, 3) definitive splenorrhaphy, and 4) splenorrhaphy failure followed by splenectomy. The authors examined age, mechanism of injury, admitting blood pressure, and severity of injury by trauma score and injury severity score. SUMMARY BACKGROUND DATA: Comparisons were made between adult (17-64 years of age) and geriatric (older than 65 years of age) patients and between patients with blunt and penetrating injury. Resource utilization (length of stay, hospital charges) and outcome (mortality) were compared. RESULTS: One thousand two hundred fifty-five patients were identified with splenic injury. Rate of splenic preservation increased over time and was achieved in more than 50% of patients through nonoperative management (40%) and splenorrhaphy (12%). Splenorrhaphy was not used commonly in either blunt or penetrating injury. Overall mortality was 13%. Geriatric patients had a higher mortality and resource utilization regardless of their mechanism of injury or method of management. CONCLUSIONS: Nonoperative management represents the prevailing method of splenic preservation in both the adult and geriatric population in North Carolina trauma center hospitals. Satisfactory outcomes and economic advantages accompany nonoperative management in this adult population.

Assessing for violence during pregnancy using a systematic approach.

OBJECTIVES: The purpose of this study was to determine whether a systematic, multiple assessment protocol could increase reporting of prenatal violence compared with a one-time routine assessment. METHOD: In 1994, the Maternity Care Coordination (MCC) program in a health department prenatal clinic in North Carolina implemented a concise, systematic assessment protocol on all 384 women who enrolled in the program from April 1994 to April 1995. The protocol assessed for violence at three times during pregnancy using the direct question, "Have you been hit, slapped, kicked, or hurt during this pregnancy?" To determine the effectiveness of the system, we retrospectively examined the 1991-1993 MCC records (n = 1056) in which the care coordinators routinely screened all clients for violence at their first visit only. RESULTS: Compared with the routine assessment approach, the new systematic assessment protocol increased reporting of prenatal violence at the initial prenatal visit from 6.3% to 10.9% (relative risk = 1.7, 95% confidence interval = 1.2, 2.5), and the multiple assessments increased reporting of prenatal violence to 14.1% (relative risk = 2.2, 95% confidence interval = 1.6, 3.1). CONCLUSIONS: Our study suggests that a concise and systematic screening technique using direct questions combined with multiple assessments increased reporting of prenatal violence compared with a single routine assessment.