Creation of a National Emergency Medicine Medical Education Journal Club.

Background There are a relatively limited number of emergency medicine (EM) medical education (MedEd) fellowships with few trainees at each program, creating barriers to local collaboration and networking. While best practices for developing MedEd journal clubs exist, there has not been an established national EM MedEd journal club. To address this need, we created a national journal club, the Council of Residency Directors (CORD) MedEd Journal Club (MEJC), to facilitate collaboration and networking opportunities by providing a synchronous online journal club. Objectives Our primary objective was to create a network for collaboration across geographical barriers to form a virtual community of practice (CoP) around the shared domain of evidence-based MedEd. Our secondary objective was to improve MedEd fellows' knowledge, skills, and attitudes surrounding MedEd research. Tertiary objectives included (1) broadening fellow exposure to key topics within MedEd, (2) describing how to develop scholarly work within MedEd, and (3) filling a perceived need for building a national MedEd virtual CoP. Curricular design The concept and objectives of the CORD MEJC were introduced to fellows and fellowship directors through a national listserv in March of 2022. Fellows volunteered to lead virtual sessions via Zoom on a monthly basis. Session fellow leaders independently chose the topics and were asked to submit two to three journal club articles discussing the topic at least two weeks in advance of each session. No topics were repeated throughout the academic year.  Impact/effectiveness Our quality improvement survey results indicated that the CORD MEJC is meeting its primary and secondary objectives. Survey results will be utilized as part of a continuous quality improvement initiative to enhance our program structure and curricula for the 2023-2024 academic year.

A workforce study of emergency medicine medical education fellowship directors: Describing roles, responsibilities, support, and priorities.

Introduction: Despite emergency medicine (EM) medical education fellowships increasing in number, the position of the medical education fellowship director (FD) remains incompletely defined. The goal of this study was to characterize the roles, responsibilities, support, and priorities for medical education FDs. Methods: We adapted and piloted an anonymous electronic survey consisting of 31 single-answer, multiple-answer, and free-response items. The survey was distributed to FDs via listserv and individual emails from a directory compiled from multiple online resources. We used descriptive statistics to analyze data from items with discrete answer choices. Using a constructivist paradigm, we performed a thematic analysis of free-response data. Results: Thirty-four medical education FDs completed the survey, resulting in a response rate of 77%. Thirty-eight percent of respondents were female. Fifty-three percent earned master's degrees in education and 35% completed a medical education fellowship. Most respondents held other education leadership roles including program director (28%), associate/assistant program director (28%), and vice chair (25%). Sixty-three percent received support in their role, including clinical buy-down (90%), administrative assistants (55%), and salary (5%). There was no difference (χ2 [2, n = 32] = 1.77, p = 0.41) between availability of support and type of hospital (community, university, or public hospital). Medical education FDs dedicated a median of 12 h per month to fellowship responsibilities, include education (median 35% of time), program administration (25%), research mentorship (15%), and recruitment (10%). Medical education FDs describe priorities that can be categorized into three themes related to fellows, fellowship, and institution. Conclusion: This study provides insight into the current position and experience of medical education FDs. The results can clarify the role and responsibilities of FDs as the demand for medical education FDs increases.

Immune check-point inhibitor-related pneumonitis: acute lung injury with rapid progression and organising pneumonia with less severe clinical disease.

AIMS: To improve understanding of the pathology of immune check-point inhibitor (ICI)-related pneumonitis, clinical, radiographic and histopathological features and outcomes were investigated in a cohort of patients who were treatment-naive before receiving ICI inhibition, who underwent lung biopsy, and in whom other potential causes of lung injury were excluded. METHODS: Patients were retrospectively identified via searches of institutional pathology and clinical records. Patients treated with other modalities for cancer and patients with lung infections or other aetiologies that could cause pneumonitis were excluded. Clinical records were reviewed by pulmonologists. Imaging studies at presentation and follow-up were reviewed by a thoracic radiologist. Pathology was reviewed by thoracic pathologists. RESULTS: Six patients with ICI-related pneumonitis were identified. Two patients presented with respiratory failure requiring mechanical ventilation, diffuse ground glass opacities (GGOs) on chest computed tomography (CT) and acute lung injury (ALI) pattern on transbronchial lung biopsies and had fatal outcomes, despite treatment. The remaining four patients presented with less severe symptoms, predominantly consolidations and patchy ground glass and part solid opacities on chest CT, organising pneumonia (OP) or chronic interstitial inflammation histologically, and showed favourable responses to treatment and remission within months. CONCLUSIONS: This study highlights two radiological-pathological patterns of ICI-related pneumonitis with different behaviour: (1) severe respiratory symptoms and diffuse GGOs on imaging correlating with ALI pattern histologically and poor prognosis; and (2) mild respiratory symptoms and consolidations or patchy subsolid opacities on imaging correlating histologically with OP or chronic interstitial inflammation and good outcomes.

Hemi-tibia allograft and free microvascularized fibula transplant reconstitute the tibia shaft with side to side healing: 7 year follow up of a 14-year-old boy with adamantinoma.

Adamantinoma is a malignant tumor that usually presents in adult men between 20 and 50 years. Due to its metastatic potential, differentiating Adamantinoma from Osteofibrous dysplasia is essential as treatment varies greatly. We present a case of limb salvage using a free microvascularized fibula transplant and hemi-tibia allograft.

Predictors of Definitive Airway Sans Hypoxia/Hypotension on First Attempt (DASH-1A) Success in Traumatically Injured Patients Undergoing Prehospital Intubation.

Background: Prehospital intubation success is routinely treated as a dichotomous outcome based on an endotracheal tube passing through vocal cords regardless of number of attempts or occurrence of hypoxia, or hypotension, which are associated with worse outcomes. We explore patient, provider, and procedure-related variables associated with successful definitive airway sans hypoxia/hypotension on first attempt (DASH-1A) in traumatically injured subjects undergoing endotracheal intubation at the scene of injury by a helicopter EMS system.Methods: This single-center retrospective chart review included patients with traumatic injuries and at least one attempted intubation by helicopter EMS at the scene of injury. Demographic and clinical variables were tested for association with DASH-1A and overall first-attempt success using univariate comparisons and multivariable logistic regression to produce adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Purposeful backwards stepwise elimination was used to develop logistic regression models for outcomes. Initial inclusion of covariates in multivariable models was based on clinical judgement, known or suspected risk factors and confounders for intubation success, and univariate associations.Results: Of 419 subjects screened, 263 met inclusion criteria. Median age was 34 years and the majority of subjects were Caucasian (95%), male (76%), and suffered blunt trauma (90%). The endotracheal tube was successfully placed on the first attempt in 198 (75.3%) of patients, but only 142 (55.3%) had a successful DASH-1A, and overall, 246 (94%) had an endotracheal tube passed successfully before hospital arrival. Factors significantly associated with successful DASH-1A were no ground EMS intubation attempt prior to arrival [aOR 2.2 (CI 1.0-4.9)], lack of airway secretions/blood [1.9 (1.0-3.4)], Cormack-Lehane Score of I and II [12.3 (4.5-33.2) & 3.2 (1.2-9.1), respectively], and bougie use [5.4 (1.8-15.8)]. For endotracheal tube passing only, the following were significantly associated with first pass success: grade of view I and II [aORs 87.3 (CI 25.8-295.7) & 6.8 (2.3-19.5), respectively], lack of secretions/blood [4.9 (2.1-11.2), bougie use [7.8 (2.3-26.3)], direct laryngoscopy [5.1 (1.5-17.0)] and not using apneic oxygenation through a nasal cannula [2.5 (1.1-5.6)].Conclusion: In our helicopter EMS system, successful endotracheal intubation on the first attempt and without an episode of hypoxia was associated with no ground EMS intubation attempt prior to flight crew arrival, lack of airway secretions/blood, Cormack-Lehane Score, and bougie use.

Pulmonary Myoepithelial Tumors With Exuberant Reactive Pneumocytes: Proposed Reclassification of So-called Pneumocytic Adenomyoepithelioma.

Pneumocytic adenomyoepithelioma (PAM) was first described in 2007 and was included in the 2015 World Health Organization Classification of lung tumors as a variant of epithelial-myoepithelial tumor. This rare pulmonary neoplasm was reported to show both myoepithelial and duct-like components, with the latter exhibiting pneumocytic differentiation with TTF-1 expression. We present an index case and 6 additional retrospectively identified cases of pulmonary tumors with prototypical features of PAM. However, with additional clinicoradiologic, histologic, immunohistochemical and cytogenetic data, we were able to reclassify them as myoepithelial neoplasms-both primary and metastatic-with entrapped exuberantly hyperplastic alveolar structures lined by TTF-1 pneumocytes. We reviewed the available literature related to PAM and myoepithelial tumors. Our cases suggest that the entity referred to as PAM represents interstitial growth of myoepithelial neoplasms enticing marked proliferation of entrapped pneumocytes rather than a distinct biphasic neoplasm with pneumocytic differentiation.

Comprehensive Next-Generation Sequencing Unambiguously Distinguishes Separate Primary Lung Carcinomas From Intrapulmonary Metastases: Comparison with Standard Histopathologic Approach.

PURPOSE: In patients with >1 non-small cell lung carcinoma (NSCLC), the distinction between separate primary lung carcinomas (SPLCs) and intrapulmonary metastases (IPMs) is a common diagnostic dilemma with critical staging implications. Here, we compared the performance of comprehensive next-generation sequencing (NGS) with standard histopathologic approaches for distinguishing NSCLC clonal relationships in clinical practice. EXPERIMENTAL DESIGN: We queried 4,119 NSCLCs analyzed by 341-468 gene MSK-IMPACT NGS assay for patients with >1 surgically resected tumor profiled by NGS. Tumor relatedness predicted by prospective histopathologic assessment was contrasted with comparative genomic profiling by subsequent NGS. RESULTS: Sixty patients with NGS performed on >1 NSCLCs were identified, yielding 76 tumor pairs. NGS classified tumor pairs into 51 definite SPLCs (median, 14; up to 72 unique somatic mutations per pair), and 25 IPMs (24 definite, one high probability; median, 5; up to 16 shared somatic mutations per pair). Prospective histologic prediction was discordant with NGS in 17 cases (22%), particularly in the prediction of IPMs (44% discordant). Retrospective review highlighted several histologic challenges, including morphologic progression in some IPMs. We subsampled MSK-IMPACT data to model the performance of less comprehensive assays, and identified several clinicopathologic differences between NGS-defined tumor pairs, including increased risk of subsequent recurrence for IPMs. CONCLUSIONS: Comprehensive NGS allows unambiguous delineation of clonal relationship among NSCLCs. In comparison, standard histopathologic approach is adequate in most cases, but has notable limitations in the recognition of IPMs. Our results support the adoption of broad panel NGS to supplement histology for robust discrimination of NSCLC clonal relationships in clinical practice.

SHORT-TERM EFFECTS OF TRIGGER POINT DRY NEEDLING ON PAIN AND DISABILITY IN SUBJECTS WITH PATELLOFEMORAL PAIN SYNDROME.

BACKGROUND: Patellofemoral pain syndrome (PFPS) is a prevalent knee disorder. A novel yet increasingly popular treatment for PFPS is trigger point dry needling (DN). PURPOSE: The purpose of this study was to determine if DN is more effective at reducing pain and disability than a sham treatment in individuals with PFPS. STUDY DESIGN: Randomized trial. MATERIALS/METHODS: Sixty military health care beneficiaries (36 males) with a clinical diagnosis of PFPS were recruited and completed the study. Subjects underwent a standardized clinical examination and were randomized into a DN or sham treatment group. DN treatment consisted of insertion of an acupuncture-like needle into six sites in the quadriceps femoris muscles of the symptomatic lower extremity based on a palpation examination. The sham grouped received a simulated treatment with a sharp object and needle guide tube without puncturing the skin. Self-reports of pain, disability, and overall status were collected before treatment, immediately after treatment and at 72 hours. Data were analyzed with separate 2x2 repeated measures analysis of variance, with independent variables being Group (DN vs. sham) and Time (pre-treatment vs. immediately post-treatment, and pre-treatment vs. 72 hours). The hypothesis of interest in each case was the Group*Time interaction. The alpha-level was set a priori to .05 using 2-tailed tests. RESULTS: Both groups exhibited a clinically meaningful reduction in pain based on numeric pain rating scale scores immediately post-treatment and at 72 hours, but there was no statistically significant difference between groups (p = 0.219, 0.310). There was no significant difference between groups for any other outcome measures. CONCLUSION: These data suggest that DN treatment is not more effective than a sham DN treatment at reducing short-term pain and disability in individuals with PFPS when used as an isolated treatment approach. LEVEL OF EVIDENCE: 2.

Impact of a Dedicated Emergency Medicine Teaching Resident Rotation at a Large Urban Academic Center.

INTRODUCTION: In the face of declining bedside teaching and increasing emergency department (ED) crowding, balancing education and patient care is a challenge. Dedicated shifts by teaching residents (TRs) in the ED represent an educational intervention to mitigate these difficulties. We aimed to measure the perceived learning and departmental impact created by having TR. METHODS: TRs were present in the ED from 12 pm-10 pm daily, and their primary roles were to provide the following: assist in teaching procedures, give brief "chalk talks," instruct junior trainees on interesting cases, and answer clinical questions in an evidence-based manner. This observational study included a survey of fourth-year medical students (MSs), residents and faculty at an academic ED. Surveys measured the perceived effect of the TR on teaching, patient flow, ease of procedures, and clinical care. RESULTS: Survey response rates for medical students, residents, and faculty are 56%, 77%, and 75%, respectively. MSs perceived improved procedure performance with TR presence and the majority agreed that the TR was a valuable educational experience. Residents perceived increased patient flow, procedure performance, and MS learning with TR presence. The majority agreed that the TR improved patient care. Faculty agreed that the TR increased resident and MS learning, as well as improved patient care and procedure performance. CONCLUSION: The presence of a TR increased MS and resident learning, improved patient care and procedure performance as perceived by MSs, residents and faculty. A dedicated TR program can provide a valuable resource in achieving a balance of clinical education and high quality healthcare.

FGF23-Associated Tumor-Induced Osteomalacia in a Patient With Small Cell Carcinoma: A Case Report and Regulatory Mechanism Study.

Tumor-induced osteomalacia (TIO) is typically caused by phosphaturic mesenchymal tumor (PMT) that secretes the phosphaturic hormone, fibroblast growth factor-23 (FGF23), resulting in decreased phosphate reabsorption in kidneys, hypophosphatemia, and finally osteomalacia. Rare cases of malignant tumor manifesting with TIO other than PMT had been reported, although in most of these reports, except one, circulating FGF23 levels were not evaluated and tissue expressing of FGF23 was not confirmed. In this article, we report a case of TIO in a patient with pulmonary small cell carcinoma with liver metastasis. The patient manifested with hypophosphatemia. His circulating level of FGF23 was markedly increased. The expression of FGF23 in tumor cells was confirmed. Furthermore, the regulatory mechanism of FGF23 in this patient was also investigated.

Results from the First Year of Implementation of CONSULT: Consultation with Novel Methods and Simulation for UME Longitudinal Training.

INTRODUCTION: An important area of communication in healthcare is the consultation. Existing literature suggests that formal training in consultation communication is lacking. We aimed to conduct a targeted needs assessment of third-year students on their experience calling consultations, and based on these results, develop, pilot, and evaluate the effectiveness of a consultation curriculum for different learner levels that can be implemented as a longitudinal curriculum. METHODS: Baseline needs assessment data were gathered using a survey completed by third-year students at the conclusion of the clinical clerkships. The survey assessed students' knowledge of the standardized consultation, experience and comfort calling consultations, and previous instruction received on consultation communication. Implementation of the consultation curriculum began the following academic year. Second-year students were introduced to Kessler's 5 Cs consultation model through a didactic session consisting of a lecture, viewing of "trigger" videos illustrating standardized and informal consults, followed by reflection and discussion. Curriculum effectiveness was assessed through pre- and post- curriculum surveys that assessed knowledge of and comfort with the consultation process. Fourth-year students participated in a consultation curriculum that provided instruction on the 5 Cs model and allowed for continued practice of consultation skills through simulation during the Emergency Medicine clerkship. Proficiency in consult communication in this cohort was assessed using two assessment tools, the Global Rating Scale and the 5 Cs Checklist. RESULTS: The targeted needs assessment of third-year students indicated that 93% of students have called a consultation during their clerkships, but only 24% received feedback. Post-curriculum, second-year students identified more components of the 5 Cs model (4.04 vs. 4.81, p<0.001) and reported greater comfort with the consultation process (0% vs. 69%, p<0.001). Post- curriculum, fourth-year students scored higher in all criteria measuring consultation effectiveness (p<0.001 for all) and included more necessary items in simulated consultations (62% vs. 77%, p<0.001). CONCLUSION: While third-year medical students reported calling consultations, few felt comfortable and formal training was lacking. A curriculum in consult communication for different levels of learners can improve knowledge and comfort prior to clinical clerkships and improve consultation skills prior to residency training.

IonFlux: a microfluidic patch clamp system evaluated with human Ether-à-go-go related gene channel physiology and pharmacology.

Ion channel assays are essential in drug discovery, not only for identifying promising new clinical compounds, but also for minimizing the likelihood of potential side effects. Both applications demand optimized throughput, cost, and predictive accuracy of measured membrane current changes evoked or modulated by drug candidates. Several competing electrophysiological technologies are available to address this demand, but important gaps remain. We describe the industrial application of a novel microfluidic-based technology that combines compounds, cells, and buffers on a single, standard well plate. Cell trapping, whole cell, and compound perfusion are accomplished in interconnecting microfluidic channels that are coupled to pneumatic valves, which emancipate the system from robotics, fluidic tubing, and associated maintenance. IonFlux™ is a state-of-the-art, compact system with temperature control and continuous voltage clamp for potential application in screening for voltage- and ligand-gated ion channel modulators. Here, ensemble recordings of the IonFlux system were validated with the human Ether-à-go-go related gene (hERG) channel (stably expressed in a Chinese hamster ovary cell line), which has established biophysical and pharmacological characteristics in other automated planar patch systems. We characterized the temperature dependence of channel activation and its reversal potential. Concentration response characteristics of known hERG blockers and control compounds obtained with the IonFlux system correlated with literature and internal data obtained on this cell line with the QPatch HT system. Based on the biophysical and pharmacological data, we conclude that the IonFlux system offers a novel, versatile, automated profiling, and screening system for ion channel targets with the benefit of temperature control.

Bonding of macromolecular hydrogels using perturbants.

This work describes a method to bond patterned macromolecular gels into monolithic structures using perturbants. Bonding strengths for a variety of solutes follow a Hofmeister ordering; this result and optical measurements indicate that bonding occurs by reversible perturbation of contacting gels. The resulting microfluidic gels are mechanically robust and can serve as scaffolds for cell culture.

Fabrication of microfluidic hydrogels using molded gelatin as a sacrificial element.

This paper describes a general procedure for the formation of hydrogels that contain microfluidic networks. In this procedure, micromolded meshes of gelatin served as sacrificial materials. Encapsulation of gelatin meshes in a hydrogel and subsequent melting and flushing of the gelatin left behind interconnected channels in the hydrogel. The channels were as narrow as approximately 6 microm, and faithfully replicated the features in the original gelatin mesh. Fifty micrometre wide microfluidic networks in collagen and fibrin readily enabled delivery of macromolecules and particles into the channels and transport of macromolecules from channels into the bulk of the gels. Microfluidic gels were also suitable as scaffolds for cell culture, and could be seeded by human microvascular endothelial cells to form rudimentary endothelial networks for potential use in tissue engineering.

Molding of three-dimensional microstructures of gels.

This Communication describes the use of patterned elastomeric stamps to mold, release, and stack hydrogels into three-dimensional microstructures. Molding of gels against stamps derivatized by a hexa(ethylene glycol)-terminated self-assembled monolayer or by an adsorbed monolayer of bovine serum albumin allowed the application of several soft lithographic techniques (replica molding, microtransfer molding, and micromolding in capillaries) to the microfabrication of gels. We describe procedures to generate coplanar or bilayered composites of gels.