The Imprecision of Sonographic Assessment of Jugular Venous Distension Among Novice Operators

ObjectiveTo assess the precision of sonographic assessment of jugular venous distension (US-JVD).MethodsSixteen emergency physicians underwent a short training in US-JVD comparable to a previously described training module. Then, they each performed US-JVD on three healthy individuals: Participant 1 with a “long, thin neck,” Participant 2 with a “normal neck,” and Participant 3 with a “short, thick neck.” The criterion standard for US-JVD was the measurements by an expert sonographer who had previously performed 100 US-JVD exams.ResultsThere were a total of 48 US-JVD measurements. Twenty-five measurements were within 1 cmH2O of the criterion standard (52%). Ten out of 16 operators were within 1 cmH2O for Participant 1, as opposed to six of out 16 and nine of out 16 for Participants 2 and 3, respectively. The range of values was largest for Participant 2 (4-11 cmH2O) and smallest for Participant 3 (6-10 cmH2O). Five measurements (10%) were wrong, indicating abnormally low measurements consistent with hypovolemia.ConclusionPhysicians were the most precise while performing US-JVD on the participant with a “short, thick neck,” and the least precise in the participant with a “normal neck.” Ten percent of the measurements misidentified these healthy participants as having hypovolemia

Is there an association between PEPFAR funding and improvement in national health indicators in Africa? A retrospective study

BACKGROUND: The US President's Emergency Plan for AIDS Relief (PEPFAR) was reauthorized in June 2008 with a three-fold increase in funds, and a broader, more explicit mandate to improve health in the low- and middle-income countries that it funded. However, the ability of a disease-specific, or vertical, programme to have a spill-over effect and improve health outcomes has been questioned. In this study, we sought to examine associations between being designated as a PEPFAR focus country (and receiving increased PEPFAR funding) and non-HIV-specific health outcomes in the World Health Organization (WHO) Africa Region, the area most affected by the HIV/AIDS epidemic. METHODS: A retrospective analysis of publicly available health outcomes data published by the World Health Organization was performed for all countries in the WHO Africa Region. Fractional changes in health indicators between 2000 and 2006 were calculated, and PEPFAR focus and non-focus countries were then compared. RESULTS: Overall, countries in the WHO Africa Region showed a small worsening in health outcomes status when all indicators were analyzed together and weighted equally. However, more health indicators improved than worsened over this six-year period. A comparison of PEPFAR focus and non-focus countries found no significant difference in the fractional change among 13 of 14 health indicators during the study period. CONCLUSIONS: This study suggests that vertical programmes, even one that is the scale of PEPFAR, may have little or no impact on health outcomes not explicitly targeted

Unconditional care in academic emergency departments

Recent news stories have explicitly stated that patients with symptoms of COVID-19 were "turned away" from emergency departments. This commentary addresses these serious allegations, with an attempt to provide the perspective of academic emergency departments (EDs) around the Nation. The overarching point we wish to make is that academic EDs never deny emergency care to any person

Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial: a protocol for the pragmatic randomised study of appendicitis treatment.

INTRODUCTION: Several European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%-15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy. OBJECTIVES: The Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for acute appendicitis aims to determine whether the antibiotic treatment strategy is non-inferior to appendectomy. METHODS/ANALYSIS: CODA is a randomised, pragmatic non-inferiority trial that aims to recruit 1552 English-speaking and Spanish-speaking adults with imaging-confirmed appendicitis. Participants are randomised to appendectomy or 10 days of antibiotics (including an option for complete outpatient therapy). A total of 500 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary analytic outcome is quality of life (measured by the EuroQol five dimension index) at 4 weeks. Clinical adverse events, rate of eventual appendectomy, decisional regret, return to work/school, work productivity and healthcare utilisation will be compared. Planned exploratory analyses will identify subpopulations that may have a differential risk of eventual appendectomy in the antibiotic treatment arm. ETHICS AND DISSEMINATION: This trial was approved by the University of Washington\u27s Human Subjects Division. Results from this trial will be presented in international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02800785

Intraocular Foreign Body: Ultrasound and CT Findings

History of present illness: A 36-year-old male with no past medical history presented to the emergency department with left eye pain. Earlier that day, the patient reported pounding a metal object with a metal hammer, when a piece flicked up and struck his eye. He was not wearing eye protection. He noted mild pain. He described his vision as being “dirty water-stained,” seeing “black, floating clouds” and “squiggly lines.” He also described the sensation of something being “stuck” in his eye. On physical exam, his vision was 20/30 in the left eye and 20/20 in the right. His extraocular movements were intact; lid and lash eversion did not reveal a foreign body. There was mild left conjunctival injection, but no tearing or purulent discharge. There was 3 mm of linear corneal fluorescein stain uptake over the anterior chamber. Significant findings: Point of care ultrasound revealed a mobile, radiolucent hyperechoic structure (see red arrow) with reverberation within the posterior chamber (see blue arrow), likely a metallic foreign body. Linear areas of mobile hyperechoic material revealed possible vitreous hemorrhage (see purple circular area). Orbital non-contrast CT confirmed a 3 mm metallic focus within the dependent portion of the left globe, lodged in the posterior sclera, with some vitreous hemorrhage but no evidence of globe rupture. Ophthalmology was consulted and the patient was taken to surgery later that night. Discussion: Patients presenting with intraocular foreign body (IOFB) can be easily missed, as they may not complain of vision loss or severe pain. Only a small entry wound may be found on careful examination. However, these seemingly harmless injuries may be vision threatening.1 The IOFB must be removed surgically in the majority of cases (>90%). 2 Bedside ultrasound is a useful tool in looking for metallic objects. Orbital CT continues to be the exam of choice.

Intraocular Foreign Body: Ultrasound and CT Findings

History of present illness: A 36-year-old male with no past medical history presented to the emergency department with left eye pain. Earlier that day, the patient reported pounding a metal object with a metal hammer, when a piece flicked up and struck his eye. He was not wearing eye protection. He noted mild pain. He described his vision as being “dirty water-stained,” seeing “black, floating clouds” and “squiggly lines.” He also described the sensation of something being “stuck” in his eye. On physical exam, his vision was 20/30 in the left eye and 20/20 in the right. His extraocular movements were intact; lid and lash eversion did not reveal a foreign body. There was mild left conjunctival injection, but no tearing or purulent discharge. There was 3 mm of linear corneal fluorescein stain uptake over the anterior chamber. Significant findings: Point of care ultrasound revealed a mobile, radiolucent hyperechoic structure (see red arrow) with reverberation within the posterior chamber (see blue arrow), likely a metallic foreign body. Linear areas of mobile hyperechoic material revealed possible vitreous hemorrhage (see purple circular area). Orbital non-contrast CT confirmed a 3 mm metallic focus within the dependent portion of the left globe, lodged in the posterior sclera, with some vitreous hemorrhage but no evidence of globe rupture. Ophthalmology was consulted and the patient was taken to surgery later that night. Discussion: Patients presenting with intraocular foreign body (IOFB) can be easily missed, as they may not complain of vision loss or severe pain. Only a small entry wound may be found on careful examination. However, these seemingly harmless injuries may be vision threatening.1 The IOFB must be removed surgically in the majority of cases (>90%). 2 Bedside ultrasound is a useful tool in looking for metallic objects. Orbital CT continues to be the exam of choice.

Scholarly Tracks in Emergency Medicine Residency Programs Are Associated with Increased Choice of Academic Career

Introduction: Career preparation in residency training is not standardized. Scholarly tracks have emerged in emergency medicine (EM) residencies to allow specialized training in an area of focus. The characteristics of these tracks and their value and impact on resident career choice are unknown. We aim to describe the current state of scholarly tracks in residency training programs and their association with pursuit of an academic career. Methods: Program leaders at EM training programs completed an online survey consisting of multiple-choice items with free-text option. Additionally, participants completed a matrix of dropdown items identifying the immediately chosen post-residency position and applicable track of each member of their graduating class. Descriptive statistics were calculated and reported for multiple-choice items. We performed comparative statistics using chi-squared and Wilcoxon rank-sum tests. Free-text responses were analyzed using a thematic approach. Results: 113/157(72%) programs participated, 51 with and 62 without tracks. Tracks were more common in four-year programs (odds ratio [OR]=4.8;[2.0–11.9]) and larger programs (chi-sq, p=0.001). Perceived benefits of tracks from programs with them included advanced training (46/50; 92%), career guidance (44/50; 88%), mentorship (44/50; 88%), and preparation for an academic career (40/50; 80%). Residents often participated in a single track (37/50; 74%) usually during their later residency years. Programs with tracks were more likely to graduate residents to an academic career, OR 1.8;[1.3–2.4]. Conclusion: This study describes the current characteristics and perceptions of scholarly tracks in EM residencies. Scholarly tracks are associated with an academic position immediately following residency. The results of this study may inform the development and use of scholarly tracks in residency training programs

Impact of a Mentorship Program on Medical Student Burnout

BackgroundBurnout can have negative consequences for providers' health and patient care. Mentorship has positive effects including stress mitigation. We sought to evaluate the impact of a mentorship program on burnout in fourth-year medical students during their 4-week emergency medicine subinternship.MethodsThis was a prospective, quasi-experimental, mixed-methods study at two institutions. We assessed burnout using the Maslach Burnout Inventory, comprising three subscales: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). We compared changes in burnout scores before and after implementation of a resident-student mentorship program. We compared categorical variables using risk ratios and continuous variables using Wilcoxon rank-sum test. To account for potential confounders, we performed multivariable analysis. Students and mentors completed an evaluative survey. We reported descriptive statistics and performed thematic qualitative analysis on free-response data.ResultsA total of 135 students (intervention = 51; control = 84) and 59 mentors participated. Intervention students demonstrated decreased EE and DP and increased PA scores, medians of -2 (-4 to 4), -1 (-3 to 2), and 1 (-1 to 4), respectively, compared to controls, median difference of 0 for all subscales. After adjusting for potential confounders, there was no significant difference in EE (mean difference = -0.2 [-0.5 to 0.2], p = 0.4) or DP scores (mean difference = -0.2 [-1.8 to 1.5], p = 0.9). There was a significant difference in PA scores (mean difference = 2.2 [0.1 to 4.3], p = 0.04). Most students felt the program positively impacted their rotation (39/48) and decreased stress (28/48). Students felt that the program provided career guidance and positively impacted their personal and professional development. The majority (34/37) of mentors enjoyed participating. Qualitative analysis revealed five major themes: relationship building, different perspective, knowledge sharing, personal fulfillment, and self-reflection.ConclusionWe found an increased sense of personal accomplishment after implementation of a mentorship program. Both mentors and mentees viewed the program positively and perceived multiple benefits