Medical Students on the Virtual Front Line: A Literature Review Elective to Provide COVID-19 Clinical Teams With Essential Information.

PROBLEM: At the Hackensack Meridian School of Medicine (HMSOM) in New Jersey, clinical activities for students were suspended on March 15, 2020, due to the COVID-19 pandemic. Clinical teams at Hackensack Meridian Health (HMH) needed resources for identifying and assimilating the medical literature regarding COVID-19, which was expanding and evolving daily. HMH leaders reached out to HMSOM leaders for assistance. The HMSOM leadership and faculty quickly organized a literature review elective. APPROACH: Eight second-year medical students participated in a literature review elective course to research and synthesize the COVID-19 clinical literature to provide synopses of best practices for various clinical teams. By March 23, students were searching the literature and writing reports independently, mentored by a senior dean (an infectious diseases specialist) and supported by the associate dean of libraries and library team. The library team updated and categorized student reports daily on a website dedicated to the elective. OUTCOMES: During the 6-week elective, 8 students produced 70 reports synthesizing the emerging COVID-19 literature to help answer practitioners' clinical questions in real time. One student report was posted on the American Academy of Ophthalmology website. All 70 were published online in Elsevier's health education faculty hub. On course evaluations, students expressed regret about not being directly involved in patient care but articulated their gratitude to be able to contribute to the clinical teams. NEXT STEPS: In June 2020, the students returned to their clinical clerkships as COVID-19 clinical volumes declined and personal protective equipment became more available. Students continued to be available to the clinical teams to assist with COVID-19 questions. This literature review elective can serve as a model for other medical schools to use to deploy students to help synthesize the evolving literature on COVID-19 or other rapidly emerging research topics.

Hydroxychloroquine and tocilizumab therapy in COVID-19 patients-An observational study.

Hydroxychloroquine has been touted as a potential COVID-19 treatment. Tocilizumab, an inhibitor of IL-6, has also been proposed as a treatment of critically ill patients. In this retrospective observational cohort study drawn from electronic health records we sought to describe the association between mortality and hydroxychloroquine or tocilizumab therapy among hospitalized COVID-19 patients. Patients were hospitalized at a 13-hospital network spanning New Jersey USA between March 1, 2020 and April 22, 2020 with positive polymerase chain reaction results for SARS-CoV-2. Follow up was through May 5, 2020. Among 2512 hospitalized patients with COVID-19 there have been 547 deaths (22%), 1539 (61%) discharges and 426 (17%) remain hospitalized. 1914 (76%) received at least one dose of hydroxychloroquine and 1473 (59%) received hydroxychloroquine with azithromycin. After adjusting for imbalances via propensity modeling, compared to receiving neither drug, there were no significant differences in associated mortality for patients receiving any hydroxychloroquine during the hospitalization (HR, 0.99 [95% CI, 0.80-1.22]), hydroxychloroquine alone (HR, 1.02 [95% CI, 0.83-1.27]), or hydroxychloroquine with azithromycin (HR, 0.98 [95% CI, 0.75-1.28]). The 30-day unadjusted mortality for patients receiving hydroxychloroquine alone, azithromycin alone, the combination or neither drug was 25%, 20%, 18%, and 20%, respectively. Among 547 evaluable ICU patients, including 134 receiving tocilizumab in the ICU, an exploratory analysis found a trend towards an improved survival association with tocilizumab treatment (adjusted HR, 0.76 [95% CI, 0.57-1.00]), with 30 day unadjusted mortality with and without tocilizumab of 46% versus 56%. This observational cohort study suggests hydroxychloroquine, either alone or in combination with azithromycin, was not associated with a survival benefit among hospitalized COVID-19 patients. Tocilizumab demonstrated a trend association towards reduced mortality among ICU patients. Our findings are limited to hospitalized patients and must be interpreted with caution while awaiting results of randomized trials. Trial Registration: Clinicaltrials.gov Identifier: NCT04347993.

The International Medical Graduate and Emergency Medicine.

International medical graduates (IMGs) are medical graduates who have received their degree from international medical schools. IMGs must undertake a 3-step process to apply to the National Residency Matching Program match. First, they must obtain a valid standard certificate from the Educational Commission for Foreign Medical Graduates. Following certification, they must apply for and secure a position in a residency training program. Third, they must obtain a visa that would enable them to commence their training. In this article, we delve thoroughly into these stepladders to provide IMGs with a clear roadmap of the process as well as contacts to key agencies that may provide more comprehensive assistance.

Uniformed Medical Students and Residents in Emergency Medicine.

"Uniformed medical students and residents" refers to medical school enrollees and physicians in training who are obligated to serve in the military after graduation or training completion. This is in exchange for 2 forms of financial support that are provided by the military for individuals interested in pursuing a career in medicine. These programs are offered namely through the Uniformed Services University of Health Sciences (USUHS) and the Health Professions Scholarship Program (HPSP). Uniformed medical school graduates can choose to serve with the military upon graduation or to pursue residency training. Residency can be completed at in-service programs at military treatment facilities, at out-service programs, at civilian residency training programs, or via deferment programs for residency training at civilian programs. Once their residency training is completed, military physicians should then complete their service obligation. As such, both USUHS and HPSP students should attend a basic officer training to ensure their preparedness for military service. In this article, we elaborate more on the mission, requirements, application, and benefits of both USUHS and HPSP. Moreover, we expand on the officer preparedness training, postgraduate education in the military, unique opportunities of military medicine, and life after completion of military obligation.

Agreement Between Serum Assays Performed in ED Point-of-Care and Hospital Central Laboratories.

INTRODUCTION: Point-of-care (POC) testing allows for more time-sensitive diagnosis and treatment in the emergency department (ED) than sending blood samples to the hospital central laboratory (CL). However, many ED patients have blood sent to both, either out of clinical custom, or because clinicians do not trust the POC values. The objective of this study was to examine the level of agreement between POC and CL values in a large cohort of ED patients. METHODS: In an urban, Level I ED that sees approximately 120,000 patients/year, all patients seen between March 1, 2013, and October 1, 2014, who had blood sent to POC and CL labs had levels of agreement measured between serum sodium, potassium, blood urea nitrogen (BUN), creatinine, and hematocrit. We extracted data from the hospital's clinical information system, and analyzed agreement with the use of Bland-Altman plots, defining both 95% confidence intervals (CIs) and more conservative CIs based on clinical judgment. RESULTS: Out of 163,661 patients seen during the study period, 14,567 had blood samples sent both for POC and CL analysis. Using clinical criteria, the levels of agreement for sodium were 98.6% (within 5mg/dL), for potassium 90.7% (0.5 mmol/L), for BUN 89.0% (within 5 mg/dL), for creatinine 94.5% (within 0.3 mg/dL), for hematocrit 96.5% (within 5 g/dL). CONCLUSION: Agreement between POC and CL values is excellent. Restricting the analysis to clinically important levels of agreement continues to show a high level of agreement. The data suggest that sending a serum sample to the hospital CL for duplicate assays is unnecessary. This may result in substantial savings and shorter ED lengths of stay.

"Deterioration to Door Time": An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients.

BACKGROUND: Timely escalation of care for patients experiencing clinical deterioration in the inpatient setting is challenging. Deterioration on a general floor has been associated with an increased risk of death, and the early period of deterioration may represent a time during which admission to the intensive care unit (ICU) improves survival. Previous studies examining the association between delay from onset of clinical deterioration to ICU transfer and mortality are few in number and were conducted more than 10 years ago. OBJECTIVE: We aimed to evaluate the impact of delays in the escalation of care among clinically deteriorating patients in the current era of inpatient medicine. DESIGN AND PARTICIPANTS: This was a retrospective cohort study that analyzed data from 793 patients transferred from non-intensive care unit (ICU) inpatient floors to the medical intensive care unit (MICU), from 2011 to 2013 at an urban, tertiary, academic medical center. MAIN MEASURES: "Deterioration to door time (DTDT)" was defined as the time between onset of clinical deterioration (as evidenced by the presence of one or more vital sign indicators including respiratory rate, systolic blood pressure, and heart rate) and arrival in the MICU. KEY RESULTS: In our sample, 64.6 % had delays in care escalation, defined as greater than 4 h based on previous studies. Mortality was significantly increased beginning at a DTDT of 12.1 h after adjusting for age, gender, and severity of illness. CONCLUSIONS: Delays in the escalation of care for clinically deteriorating hospitalized patients remain frequent in the current era of inpatient medicine, and are associated with increased in-hospital mortality. Development of performance measures for the care of clinically deteriorating inpatients remains essential, and timeliness of care escalation deserves further consideration.

Professional Societies, Political Action Committees, and Party Preferences.

Societies representing physician specialties and other health care personnel commonly have political action committees (PACs). These PACs seek to advance their members' interests through advocacy and campaign contributions. We examined contribution data for health care workers' PACs from the 2010 to 2012 election cycles and found that higher annual income was strongly associated with greater giving to Republican candidates. Patterns of giving may offer insights into various medical workers' party preferences, political leanings, and views of health care reform.

What affects time to care in emergency room appendicitis patients?

BACKGROUND: Emergency departments (EDs) provide a safety net for seriously ill individuals. Little is known about factors that affect time to diagnosis and treatment of patients with time-sensitive conditions within the ED. METHODS: Retrospective observational study of 236 appendicitis patients examining patient factors and ED characteristics with time to a surgeon's diagnosis of appendicitis and ED length of stay (LOS). RESULTS: Time to surgeon's diagnosis and ED LOS were slower for nonwhite patients without private insurance (parameter estimate = 0.38, P = 0.002 and 0.31, P < 0.001, respectively) and quicker for patients for whom the ED physician's diagnostic first impression was appendicitis (parameter estimate = -0.29, P = 0.003 and -0.14, P = 0.04, respectively). Greater numbers of physicians staffing the ED had a modest effect on time to surgeon diagnosis and ED LOS (parameter estimate = -0.04, P = 0.01 and -0.04, P = 0.01, respectively), whereas greater numbers of patients had little impact (parameter estimate = -0.005, P = 0.04 and -0.002, P = 0.28, respectively). CONCLUSIONS: Minority patients without private insurance had slower times to specialist consultation and treatment; ED staffing and census had a small effect. To maximize patient safety and ED quality of care, administrators should ensure timely specialist consultation and determine additional mechanisms facilitating white privately insured patients' quicker care.