bluuebunny/crossref_metadata_2025_split huggingface dataset:
Approach to Formalized Ultrasound Credentialing in a Community Hospital Health System with both Academic and Non-Academic Clinical Settings
Authors: Long Jeremy , Meyering Stefan , Scheel Timothy 
Published: February 2021

INTRODUCTION In the US, ultrasound in Emergency Medicine (EM) is widely considered the standard of care in clinical practice amongst most Emergency Department providers. At the authors’ institution and affiliates, there were a variety of health care providers utilizing ultrasound for clinical practice, and their skill levels varied, dependent on training and exposure. As an attempt to standardize credentialing practice and determine need for additional training thresholds, the authors endeavored to perform a skills assessment utilizing both written and clinical based practical assessments. METHODS A 7 point questionnaire was administered to a convenience sample of providers requesting formal training information, number of ultrasounds performed, and self-assessed competency. A 10 point written assessment with ultrasound knowledge and clinical application questions was also administered. A subsequent clinical assessment on live humans and models was then performed with multiple stations assessing 15 different instrumentation skills and technique, as well as image interpretation and evaluation. RESULTS A total of 23 attending EM board-certified physicians, and four advanced practice providers (PA and NP) took the credentialing assessments scoring an average of 7.3 out of 10 (SD 0.83) for the written assessment. Twenty (71%) of the 28 tested passed the clinical evaluation on their initial attempt. Five (17%) passed on a first remediation. Three (10%) required more than one initial revision attempt. All those who did remediate were able to complete the revision with a passing score. CONCLUSIONS Overall, the testing was considered a successful process. This program appears to have offered a level of standardization that was appealing to the credentialing body at our institution. We were able to assess to a level of competence considered standard of care by national credentialing bodies.
Discovering Pathologies in the Anatomy Lab: The Case of Brachial Plexopathy Mimicking Neurological Thoracic Outlet Syndrome
Authors: Mancine Ryley , Kowalski Paul , McMillan William , Geske Nicole , Kujjo Loro 
Published: February 2021

CONTEXT Well-established human anatomy labs with access to expert faculty are exceedingly valuable tools to medical student education. In this manuscript, we detail an infero-lateral subclavicular lipoma which was discovered as a result of the utilization of both those labs and expert faculty. This lipoma may have caused brachial plexopathy or may serve as an unusual cause of neurologic thoracic outlet syndrome (NTOS) due to the location of the mass. EDUCATIONAL CASE PRESENTATION During prosection of a donor in the human anatomy lab, a mass was discovered by a medical student. This medical student utilized the human anatomy lab faculty members and resources to identify the mass as a lipoma. The lipoma compressed the lateral cord of the brachial plexus and the suprascapular nerve, but no diagnosis of NTOS or brachial plexopathy was made during the life of the donor, nor was any surgical intervention indicated. Removal of the lipoma immediately relieved stress upon the nerves. Histochemical analysis confirmed the diagnosis of a lipoma and demonstrated almost only mature adipocytes. CONCLUSION The authors concluded that the lipoma of this patient was not identifiable with computerized tomography imaging modalities, despite ultrasound demonstrating a hyperechoic outline of the mass in the cadaver of the patient. It is very likely that this lipoma had not been diagnosed previously due to the atypical location of the tumor. Equally, typical surgical methods associated with brachial plexopathy or NTOS treatment would be difficult or more complicated, due to the lateral and inferior location of the lipoma. Physicians treating thoracic outlet syndrome-type symptoms without resolution should consider potential non-malignant obstruction located outside the thoracic outlet, toward the extremity. Deep palpatory methods and physical therapy should be considered until diagnosis is certain, as ultrasound would be difficult and typical transaxillary surgical methods would be nonhelpful. Medical students and early-career residents and physicians should be aware of the resources provided to them via campus human anatomy laboratories which they may utilize to further their understanding and knowledge of specific pathologies.
Evaluation of a COVID-influenced Curriculum to Address Food Insecurity in a Detroit Family Medicine Residency Clinic
Authors: Ghouse Amrien , Gunther William , Sebastian Matthew 
Published: February 2021

CONTEXT To date, numerous projects have demonstrated that an ongoing limited access to nutritionally dense food (i.e., “food insecurity”) plays a key role in the overall health and wellbeing of lower income at-risk populations. METHODS For this 2019-2020 pilot project, the resident physician authors first created and administered a simple five-item questionnaire screening process to systematically identify food insecure patients in their metropolitan Detroit residency clinic. A sample of patients who had been identified as food insecure and pre-diabetic were then provided improved access to healthy foods, supplemented by a six-week program of nutritional education classes using a nationally recognized “Cooking Matters’’ six-week long curriculum with a licensed chef and nutrition educator RESULTS After institutional review board approval, the authors enrolled a sample of 10 adults. The authors successfully measured both pre- and post-program Hemoglobin A1c (HbA1C) levels for all participants who completed the required course and subsequent clinic follow up visits. Using a series of initial non-parametric Wilcoxon Signed Rank matched pair tests, post-program follow-up at three months revealed statistically significant reductions in documented HbA1c levels from baseline for six enrolled patients (W=1, Z = - 2.226, p = 0.026) and six-month follow up (i.e., more than four months after completion of the program) (W = 1, Z = - 2.060, p = 0.039). In post-program surveys, each respondent indicated that they found the class content to be generally beneficial to increase their nutritional knowledge. CONCLUSIONS In the authors’ setting, this food insecurity program has subsequently led to a more formal screening process to evaluate and identify food insecure patients. The authors discuss the scheduling difficulties they experienced from the COVID-19 pandemic for their sample patients. However, these pilot results suggest that prolonged benefits may require ongoing “virtual” teaching sessions with pre-diabetic patients to address the complex factors influencing food insecurity levels identified in similar inner-city settings.
The Relationship between In-Training Examinations and Simulation Assessments in an Emergency Medicine Residency Program
Authors: Clarke Sheri L. , Eydgahi Ali 
Published: February 2021

CONTEXT Historically, the assessment of medical resident knowledge and skill has occurred through annual in-training examinations and faculty observation during real patient encounters. To improve patient care and the learning environment, medical educators have begun creating simulation experiences for medical residents to perform procedures without using real patients. However, simulation curricula and accompanying assessment techniques have not been standardized. Using a longitudinal record review, in-training examination scores were compared to annualized simulation assessment scores to see if there is any relationship between the assessment types. METHODS This project was a retrospective eight-year study from a single residency program. The scores were collected from 102 resident academic records from 2007 to 2015 for the annual American Board of Emergency Medicine in-training examination and the resident’s annual simulation assessment. Complete data sets were analyzed to determine if a relationship exists between the assessment methods. Then the averages were compared for only the first three years for all students and for all four years for osteopathic residents as they have an additional fourth year of training. RESULTS This study showed a lack of relationship between the two assessment types when reviewing three years of data. When the fourth year data is considered, there was a significant relationship between the assessment types. CONCLUSIONS The performance scores for both types of assessment provide independent information on the resident progress in training. Therefore, they should both be reviewed and considered to appropriately measure the resident’s performance. The significance of the fourth year of training for osteopathic residents requires further study.
The Use of Magnetic Resonance Cholangiopancreatography (MRCP) in the Setting of Acute Pancreatitis: When is it Most Useful?
Authors: Sevensma Karlin , Allen Miranda , Harden Rebecca , Corser William 
Published: February 2021

CONTEXT The usefulness of MRCP in the workup of acute pancreatitis has long been debated. METHODS 2013-2016 chart review data were collected by the authors from adult patients with acute pancreatitis who also had received Magnetic Resonance Cholangiopancreatography (MRCP). Those patients were categorized by diagnosis and according to whether or not the MRCP changed healthcare services. RESULTS Changes in care were significantly correlated with diagnosis and elevated liver function tests (LFT). The patients who benefitted most from MRCP were those with acute gallstone pancreatitis (r = 0.298, n = 109, p = 0.002) and patients with elevated LFT (r = 0.219, n = 89, p= 0.040). The most common way that MRCP influenced the care of patients with acute gallstone pancreatitis was by allowing providers to forego intraoperative cholangiogram (IOC) when MRCP results were negative (r = 0.335, n = 109, p < 0.001). CONCLUSIONS The authors conclude that this was not the most cost effective management practice since the cost of intraoperative cholangiogram was about one quarter that of MRCP. Limiting MRCP use in patients with acute gallstone pancreatitis and preferentially using IOC at the time of surgery can likely decrease hospital costs without compromising care.
Comparison of Acute Kidney Injury During Treatment with Vancomycin and either Piperacillin-Tazobactam or Meropenem
Authors: Cannon John M. , Douce Richard W. , Grubbs Erin R. , Wills Christopher B. , Khan Asam , Schmidt Elizabeth M. , Wang Michael S. 
Published: February 2021

CONTEXT Empiric antibiotics are often required in hospitalized patients with serious infections who may be septic and at risk for drug resistant organisms. The purpose of this study was to evaluate the observed incidence of acute kidney injury (AKI) in a sample of adult patients receiving either piperacillin-tazobactam and vancomycin or meropenemvancomycin for at least 72 hours. METHODS Single-center, retrospective matched cohort at a 200-bed Regional Community Medical Center. Adult patients were included in the sample if they were without preexisting renal dysfunction and admitted over an 18-month time period to receive either the combination of piperacillin-tazobactam and vancomycin or meropenem-vancomycin. Sample patients were evaluated for AKI. This condition was defined by the authors as an increase in serum creatinine of 0.5mg/ml or an increase of 50% above baseline during the duration of antibiotic treatment. RESULTS A total of 266 patients receiving either combination of antibiotics were evaluated for AKI. The incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (n = 74/292, 25%) compared with the meropenem-vancomycin group (n=8/74, 9.5%, p=0.008). CONCLUSIONS The results of this study suggest that the combination of piperacillin-tazobactam and vancomycin is associated with an increased incidence of AKI. Higher vancomycin trough concentrations were associated with increased risk for development of AKI.
Improving Pneumococcal Vaccination Rates in a Community-Based Internal Medicine Resident Clinic
Authors: Sebald Cale , Joubert Lana , Novakosky Marcella , Rosel MaryEllen 
Published: February 2021

CONTEXT Despite proven benefits of vaccination such as reduced morbidity and mortality, many patients remain out of date on their recommended vaccines. The goal of this pilot project was to develop and test a systematic vaccination review and ordering protocol aimed to increase the percentage of patients who were assessed under current pneumococcal vaccine recommendations by 5%. METHODS The study location was set in a community-based internal medicine resident clinic in Muskegon, Michigan, with the patient population coming from the same setting. Data from 50 patients who had completed office visit appointments at a resident clinic from January 2016 through April 7th, 2017 were randomly extracted before implementation of the protocol. Two months post-implementation, the authors obtained office visit data from another randomly selected 50 clinic patients for comparison. The nurses and medical assistants in the office had been educated on the pneumonia vaccine protocol based on CDC (United States Centers for Disease Control and Prevention) vaccination guidelines and state registry records. They were also provided copies of the seven-step vaccine assessment and ordering protocol that included obtaining MCIR (Michigan Care Improvement Registry) data to update the patient’s chart for a possible provider order set. Clinic residents were also educated on CDC pneumonia vaccine guidelines, and the authors posted several guideline related posters on clinic walls. RESULTS The authors initially compared the percentage of patients who providers had assessed regarding their vaccination status before protocol implementation to the percentage of patients after protocol implementation. There was a 10% post-implementation increase in pneumonia vaccination assessment. CONCLUSIONS Although the results of this pilot project are obviously limited by methodological and sample size characteristics, the initially measured improvements in vaccination status suggests that this type of systematic protocol approach may warrant further testing in similar settings.
Chief Resident Skills: A Study on Resident Perceptions of Skill Importance and Confidence
Authors: VanOrder Tonya , Wisniewski Samuel J. 
Published: February 2021

CONTEXT Chief residents (CRs) generally play a pivotal role in the graduate medical education mission to facilitate the professional development of resident physicians. Courses designed to prepare CRs for their new role previously have primarily focused on developing their teaching, evaluation and interpersonal communication skills. What remains unclear is how different types of residents (CRs versus Non-CRs and men versus women) may vary in their perception of how important particular skills are, and their confidence in performing these same skills. The purpose of this cross-sectional descriptive correlational study was to investigate the potential differences in sample respondents’ perceived importance of CR skills and respondents’ perceived confidence to perform these skills. METHODS The authors administered a 28-item survey questionnaire to a population of 457 CR and Non-CR respondents from 20 clinical specialties regarding their perceived importance of 11 skills, as well as their self-assessed confidence in performing each skill. This study also sought to examine whether gender-based differences existed for the perceived importance and confidence of these same CR skills. RESULTS Statistically significant differences in perceived importance and confidence levels between sample subgroups for the majority of key CR skills were observed. When asked about importance of CR skills, both CR and Non-CR respondents identified administrative and time management skills as most important, contrary to the other types of skills (e.g., teaching skills) the authors had generally expected to be most highly rated. As expected, the largest overall gap in perceived importance and self-reported confidence as either a CR or Non-CR was in the area of conflict management. Males reported higher confidence than females in each of the CR skills, with differences for five items found to be statistically significant. (p < 0.05) CR respondents also reported higher confidence in performing 10 of 11 skills at statistically significant levels. (p < 0.05) CONCLUSIONS Although this project contributes baseline data from a relatively large sample, further studies are still required to replicate these results in other resident populations to further examine the perceptions of contemporary resident physicians concerning this vital role.
Cardiovascular Factors Associated with Septic Shock Mortality Risks
Authors: Arnautovic Jelena , Mazhar Areej , Souther Britni , Mikhijan Gary , Boura J. , Huda Najia 
Published: February 2021

CONTEXT The presence of at least one underlying chronic health condition, such as long-term care facility residence, malnutrition, immunosuppression, or prosthetic device use, are well known factors increasing infection risks and progression to severe sepsis. Furthermore, some degree of cardiovascular dysfunction occurs in the majority of septic patients and this prognostic significance has become increasingly recognized. Since septic shock carries the highest mortality risk on the sepsis spectrum, it is important to evaluate the cardiovascular risk impact on mortality in this subset of patients. METHODS The retrospective parent study contributing these electronic health record data was IRB approved and conducted across four hospital intensive care units within the authors’ Michigan healthcare system. Patients with cardiopulmonary arrest or transfers from an outside facility were excluded. The authors evaluated the presence of modifiable and non-modifiable cardiovascular risk factors in septic shock patients upon admission to an emergency department. RESULTS The authors’ final analytic sample included n = 109 adults who were discharged alive compared to those who died during hospitalization. Those patients who died were more often male with an underlying history of hypertension, congestive heart failure, coronary artery disease, or peripheral arterial diseases, were taking pre-admission beta-blocker medications, and had higher APACHE II scores at admission compared to the patients who survived to discharge. Significantly higher mortality risks were found in sample patients with increased troponin levels on admission and atrial fibrillation. CONCLUSIONS Appropriate triage and prompt treatment of these patient groups with tailored therapy to stabilize and improve cardiac dysfunction in the emergency department could potentially lead to improved survival outcomes. Clinicians need more studies to determine therapeutic targets most impacting underlying pathophysiologic mechanisms such as elevated troponin and atrial fibrillation that greatly increase mortality risks.
Are Emergency Medicine Residents Provided Adequate Training in Patient-Centered Communication?: A Resident Survey
Authors: Stillman Kimberly , Kellar Jesse 
Published: February 2021

CONTEXT Emergency Medicine residents frequently face challenging communication situations. Little is known regarding resident comfort level and amount of training received in managing these types of patient care scenarios. The purpose of this study was to measure the relationships between Emergency Medicine resident comfort levels, reported amount of patient-centered communication training received and correlation between amount of GME training and comfort levels when handling difficult situations in emergency departments. METHODS In 2016, the authors used the Council of Emergency Medicine Residency Directors (CORD) listserv to disseminate an online survey to Emergency Medicine residents. Survey content came from the Patient Centered Communication subsection of The American Board of Emergency Medicine Milestones. This survey included five different patient scenarios. RESULTS There were a total of 306 completed surveys. Residents rated their comfort level as most comfortable in scenarios regarding exhibiting empathy and least comfortable when providing bad news to patients or dealing with drug-seeking patients and difficult family members. Training was most prevalent in the areas of exhibiting empathy and giving bad news and lowest in managing drug-seeking patients and difficult patients. CONCLUSIONS This survey revealed that Emergency Medicine residents do not consider themselves generally comfortable in multiple communication scenarios and that the amount of training received in these areas is often lacking during residency. A statistically significant positive correlation existed between comfort level and amount of graduate medical training in most areas. Results suggest that increasing the amount of communication training during residency may be of benefit in influencing how comfortably residents handle difficult patient scenarios.
Observed Clinical, Laboratory, and Echocardiographic Parameters in Takotsubo Syndrome Patients with Mortality and Decreased Ejection Fraction During Initial Hospital Admission
Authors: Hinojos Andrew , Vanhecke Thomas E. , Manning Stephen 
Published: February 2021

CONTEXT Approximately 1-2% of patients with suspected acute coronary syndrome also develop Takotsubo syndrome (TTS). This syndrome is characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle that mimics myocardial infarction in the absence of obstructive coronary artery disease. Up to 21.8% of TTS patients develop serious complications, including death. Currently, there is no consensus on management of these patients and their complications. Thus, identifying TTS patients at higher risk for complications becomes valuable in managing their hospital course. The aim of this study was to examine the predictive significance of laboratory, echocardiographic, and clinical parameters on in-hospital mortality in a sample subgroup of TTS patients. Secondary analyses were performed on patients with reduced (i.e., <35%) ejection fractions. METHODS This retrospective study at a community hospital identified patients from October 1, 2009 to August 31, 2015 who presented with ACS and underwent cardiac catheterization. Patients were diagnosed with TTS by features of cardiomyopathy on cardiac catheterization or echocardiogram. RESULTS The authors analyzed data from a total of 177 eligible patients identified with TTS. The in-hospital mortality rate was 5.65%. Compared to the non-mortality subgroup, patients who suffered in-hospital mortality had significantly lower diastolic blood pressure on admission (p < 0.050), lower hemoglobin levels (p < 0.001), lower sodium (p = 0.020), higher blood urea nitrogen (p = 0.009), lower glomerular filtration rate (p = 0.016), and lower albumin levels (p < 0.001). Cox regression analyses demonstrated admission hemoglobin was significant, yielding a mortality hazard ratio of 0.760 (95% CI of 0.594-0.972, p = 0.029). CONCLUSIONS Patients who present with TTS and hypotension, anemia, low albumin levels, elevated lactic acid and renal dysfunction were associated with higher rates of in-hospital mortality in this study’s sample population. Further, admission hemoglobin had the strongest association with death. Every unit decrease in hemoglobin increased mortality risk by 24%.