Too Big Too Fast? Potential Implications of the Rapid Increase in Emergency Medicine Residency Positions

Emergency medicine (EM) has expanded rapidly since its inception in 1979. Workforce projections from current data demonstrate a rapid rise in the number of accredited EM residency programs and trainee positions. Based on these trends, the specialty may soon reach a point of saturation, particularly in urban areas. This could negatively impact future trainees entering the job market as well as the career plans of medical students. More time and resources should be devoted to obtaining accurate projections, assessing the distribution of emergency physicians in rural versus urban settings, and implementing central workforce planning to protect the future of graduating trainees.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154425/1/aet210400.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154425/2/aet210400_am.pd

The Parallel Encounter: An Alternative to the Traditional Serial Trainee–Attending Patient Evaluation Model

BackgroundThe emergency department environment requires the clinician‐educator to use adaptive teaching strategies to balance education with efficiency and patient care. Recently, alternative approaches to the traditional serial trainee–attending patient evaluation model have emerged in the literature.MethodsThe parallel encounter involves the attending physician and resident seeing the patient independently. Instead of the trainee delivering a traditional oral case presentation, the trainee does not present the history and examination to the attending physician. Rather, the attending and trainee come together following their independent evaluations to jointly discuss and formulate the assessment and plan.ResultsThe parallel encounter has the potential to enhance the teaching encounter by emphasizing clinical reasoning, reduce cognitive bias by integrating two independent assessments of the same patient, increase attending workflow flexibility and efficiency, and improve patient satisfaction and outcomes by reducing time to initial provider contact. The attending must be mindful of protecting resident autonomy. This model tends to work better for more senior learners.ConclusionsThe parallel encounter represents a novel approach to the traditional serial trainee–attending patient evaluation model that may enhance the teaching encounter and improve patient care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163487/2/aet210491_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163487/1/aet210491.pd

In Crisis: Medical Students in the COVID‐19 Pandemic

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156130/2/aet210450.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156130/1/aet210450_am.pd

Zooming In Versus Flying Out: Virtual Residency Interviews in the Era of COVID‐19

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163370/2/aet210486.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163370/1/aet210486_am.pd

What’s in a Name? Use of Brand versus Generic Drug Names in United States Outpatient Practice

BACKGROUND: The use of brand rather than generic names for medications can increase health care costs. However, little is known at a national level about how often physicians refer to drugs using their brand or generic names. OBJECTIVE: To evaluate how often physicians refer to drugs using brand or generic terminology. DESIGN AND PARTICIPANTS: We used data from the 2003 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of 25,288 community-based outpatient visits in the United States. After each visit, patient medications were recorded on a survey encounter form by the treating physician or transcribed from office notes. MEASUREMENTS: Our main outcome measure was the frequency with which medications were recorded on the encounter form using their brand or generic names. RESULTS: For 20 commonly used drugs, the median frequency of brand name use was 98% (interquartile range, 81–100%). Among 12 medications with no generic competition at the time of the survey, the median frequency of brand name use was 100% (range 92–100%). Among 8 medications with generic competition at the time of the survey (“multisource” drugs), the median frequency of brand name use was 79% (range 0–98%; P < .001 for difference between drugs with and without generic competition). CONCLUSIONS: Physicians refer to most medications by their brand names, including drugs with generic formulations. This may lead to higher health care costs by promoting the use of brand-name products when generic alternatives are available

Rapid Adaptation to Remote Didactics and Learning in GME

Weekly didactic conference in emergency medicine education has traditionally united residents and faculty for learning and fostered community within the residency program. The global pandemic Coronavirus Disease-19 (COVID-19) has fueled a rapid transition to remote learning that has disrupted the typical in-person format. To maintain ACGME educational experiences and requirements for residents in a safe manner, many residencies have moved to videoconferencing platforms such as Zoom™, Teams™, and WebEX.™ Given the importance of didactic conference as a ritual, educational experience and community-building activity, most residency programs have worked to maintain an active and robust didactic conference despite the many logistical challenges. Engaging residency program members in the transition to remote learning and utilizing opportunities for innovation can help to maintain normalcy and combat isolation resulting from the loss of weekly in-person contact. Herein, we propose practical tips for optimizing remote learning for weekly emergency medicine residency didactics

The Key Events Dose-Response Framework: Its Potential for Application to Foodborne Pathogenic Microorganisms

The Key Events Dose-Response Framework (KEDRF) is an analytical approach that facilitates the use of currently available data to gain insight regarding dose-response relationships. The use of the KEDRF also helps identify critical knowledge gaps that once filled, will reduce reliance on assumptions. The present study considers how the KEDRF might be applied to pathogenic microorganisms, using fetal listeriosis resulting from maternal ingestion of food contaminated with L. monocytogenes as an initial example. Major biological events along the pathway between food ingestion and the endpoint of concern are systematically considered with regard to dose (i.e., number of organisms), pathogen factors (e.g., virulence), and protective host mechanisms (e.g., immune response or other homeostatic mechanisms). It is concluded that the KEDRF provides a useful structure for systematically evaluating the complex array of host and pathogen factors that influence the dose-response relationship. In particular, the KEDRF supports efforts to specify and quantify the sources of variability, a prerequisite to strengthening the scientific basis for food safety decision making

Impact of the COVID-19 Pandemic on the Clinical Learning Environment: Addressing Identified Gaps and Seizing Opportunities

The clinical learning environment (CLE) encompasses the learner’s personal characteristics and experiences, social relationships, organizational culture, and the institution’s physical and virtual infrastructure. During the COVID-19 pandemic, all four of these parts of the CLE have undergone a massive and rapid disruption. Personal and social communications have been limited to virtual interactions or shifted to unfamiliar clinical spaces because of redeployment. Rapid changes to the organizational culture required prompt adaptations from learners and educators in their complex organizational systems yet caused increased confusion and anxiety among them. A traditional reliance on a physical infrastructure for classical educational practices in the CLE was challenged when all institutions had to undergo a major transition to a virtual learning environment. However, disruptions spurred exciting innovations in the CLE. An entire cohort of physicians and learners underwent swift adjustments in their personal and professional development and identity as they rose to meet the clinical and educational challenges they faced due to COVID-19. Social networks and collaborations were expanded beyond traditional institutional walls and previously held international boundaries within multiple specialties. Specific aspects of the organizational and educational culture, including epidemiology, public health, and medical ethics, were brought to the forefront in health professions education, while the physical learning environment underwent a rapid transition to a virtual learning space. As health professions education continues in the era of COVID-19 and into a new era, educators must take advantage of these dynamic systems to identify additional gaps and implement meaningful change. In this article, health professions educators and learners from multiple institutions and specialties discuss the gaps and weaknesses exposed, opportunities revealed, and strategies developed for optimizing the CLE in the post–COVID-19 world

Methodologies for in vitro and in vivo evaluation of efficacy of antifungal and antibiofilm agents and surface coatings against fungal biofilms

KT acknowledges receipt of a mandate of Industrial Research Fund (IOFm/05/022). JB acknowledges funding from the European Research Council Advanced Award 3400867/RAPLODAPT and the Israel Science Foundation grant # 314/13 (www.isf.il). NG acknowledges the Wellcome Trust and MRC for funding. CD acknowledges funding from the Agence Nationale de Recherche (ANR-10-LABX-62-IBEID). CJN acknowledges funding from the National Institutes of Health R35GM124594 and R21AI125801. AW is supported by the Wellcome Trust Strategic Award (grant 097377), the MRC Centre for Medical Mycology (grant MR/N006364/1) at the University of Aberdeen MaCA: outside this study MaCA has received personal speaker’s honoraria the past five years from Astellas, Basilea, Gilead, MSD, Pfizer, T2Candida, and Novartis. She has received research grants and contract work paid to the Statens Serum Institute from Astellas, Basilea, Gilead, MSD, NovaBiotics, Pfizer, T2Biosystems, F2G, Cidara, and Amplyx. CAM acknowledges the Wellcome Trust and the MRC MR/N006364/1. PVD, TC and KT acknowledge the FWO research community: Biology and ecology of bacterial and fungal biofilms in humans (FWO WO.009.16N). AAB acknowledges the Deutsche Forschungsgemeinschaft – CRC FungiNet.Peer reviewedPublisher PD

Toll-Like Receptor 2 Induced Angiogenesis and Invasion Is Mediated through the Tie2 Signalling Pathway in Rheumatoid Arthritis

BACKGROUND: Angiogenesis is a critical early event in inflammatory arthritis, facilitating leukocyte migration into the synovium resulting in invasion and destruction of articular cartilage and bone. This study investigates the effect of TLR2 on angiogenesis, EC adhesion and invasion using microvascular endothelial cells and RA whole tissue synovial explants ex-vivo. METHODS: Microvascular endothelial cells (HMVEC) and RA synovial explants ex vivo were cultured with the TLR2 ligand, Pam3CSK4 (1 µg/ml). Angiopoietin 2 (Ang2), Tie2 and TLR2 expression in RA synovial tissue was assessed by immunohistology. HMVEC tube formation was assessed using Matrigel matrix assays. Ang2 was measured by ELISA. ICAM-1 cell surface expression was assessed by flow cytometry. Cell migration was assessed by wound repair scratch assays. ECM invasion, MMP-2 and -9 expression were assessed using transwell invasion chambers and zymography. To examine if the angiopoietin/Tie2 signalling pathway mediates TLR2 induced EC tube formation, invasion and migration assays were performed in the presence of a specific neutralising anti-Tie2mAb (10 ug/ml) and matched IgG isotype control Ab (10 ug/ml). RESULTS: Ang2 and Tie2 were localised to RA synovial blood vessels, and TLR2 was localised to RA synovial blood vessels, sub-lining infiltrates and the lining layer. Pam3CSK4 significantly increased angiogenic tube formation (p<0.05), and upregulated Ang2 production in HMVEC (p<0.05) and RA synovial explants (p<0.05). Pam3CSK4 induced cell surface expression of ICAM-1, from basal level of 149±54 (MFI) to 617±103 (p<0.01). TLR-2 activation induced an 8.8±2.8 fold increase in cell invasion compared to control (p<0.05). Pam3CSK4 also induced HMVEC cell migration and induced MMP-2 and -9 from RA synovial explants. Neutralisation of the Ang2 receptor, Tie2 significantly inhibited Pam3CSK4-induced EC tube formation and invasion (p<0.05). CONCLUSION: TLR2 activation promotes angiogenesis, cell adhesion and invasion, effects that are in part mediated through the Tie2 signalling pathway, key mechanisms involved in the pathogenesis of RA