Program Signaling in Emergency Medicine: The 2022-2023 Program Director Experience.

Introduction: Program signaling (PS), which enables residency applicants to signal their preference for a specific program, was introduced in emergency medicine (EM) in the 2022-2023 residency application cycle. In this study we evaluated EM program directors' (PD) utilization of PS in application review and ranking. This study also explores the relationship between program characteristics and number of signals received as well as the relative importance and utilization of signals related to the number of signals received. Methods: This is an institutional review board-approved, cross-sectional study of PDs at Accreditation Council for Graduate Medical Education-accredited EM residency programs. We used descriptive statistics to describe the characteristics of residency programs and practices around PS. Measures of central tendency and dispersion summarized continuous variables. We used chi-square analysis or the Fisher exact test for comparisons between groups for categorical variables. Comparisons for continuous variables were made using the t-test for independent samples or analysis of variance. Results: The response rate was 41% (n = 113/277 EM programs). Most programs participated in PS (n = 261/277 EM programs, 94.2%). Mean number of signals received was 60 (range 2-203). Signals received varied based on program characteristics including geographic location and program type, duration, environment, and longevity. Most used PS in holistic review (52.2%), but other uses varied by proportion of applications that were signaled. The importance of PS in application review (mean 2.9; 1-5 scale, 1 = not important, 5 = extremely important) and rank list preparation (2.1) was relatively low compared to other application elements such as standardized letters of evaluation (4.97 for review, 4.90 for ranking). Conclusion: The study provides insights into PS utilization in EM's inaugural year. We have identified patterns of signal use based on program characteristics and number of signals received that can inform signal allocation and utilization on an individual applicant and program level. A more nuanced understanding of signal use can provide valuable insight as the specialty of EM grapples with fluctuations in its applicant numbers and shifting demographics of its applicant pool.

CFTR Modulator Therapy in an Individual With Cystic Fibrosis Caused by a N1303K CFTR Variant and Infected With Mycobacterium abscessus.

This report describes a case of a 15-year-old male with cystic fibrosis caused by N1303K and Q493X cystic fibrosis transmembrane conductance regulator (CFTR) protein variants. In this case, CFTR modulators including tezacaftor-ivacaftor and subsequently elexacaftor-tezacaftor-ivacaftor were used and resulted in clinical stability and improvement.

Procedural Competency in Academic Emergency Medicine Attending Physicians: How Is Competency Maintained and Evaluated by Academic Institutions in the US?

Introduction There have been numerous studies examining the minimum graduation requirements for resident training of procedural skills within Emergency Medicine programs; however, how academic medical centers in the United States maintain Emergency Medicine attending procedural skill competency has not been explored. Objectives The aim of this study was to examine the processes in place to evaluate and track the procedural skills practices of Emergency Medicine attending physicians at academic institutions in the US. Methods An exploratory cross-sectional survey was sent to all 39 ACGME-accredited Emergency Medicine programs in the US through a REDCap survey in 2020. Survey items inquired about the current methods in place to maintain competence on 13 procedural skills performed by Emergency Medicine providers. Results The survey response rate was 26.9%. The majority of programs did not have a process in place to evaluate procedural skills at the time of initial appointment (74.3%), and almost half of participating programs reported no formalized process during employment (51.3%). Institutions reported no minimum required number for the following procedures: dislocation reduction, intraosseous placement, lateral canthotomy, lumbar puncture, paracentesis, pericardiocentesis, thoracentesis, transvenous cardiac pacing, and tube thoracostomy. For central venous access, cricothyrotomy, endotracheal intubation, and procedural sedation, 25.6% or less of institutions had minimum annual requirements. Conclusion This study summarized the current methods in place to assess Emergency Medicine attending procedural skills at US academic institutions and demonstrated that the majority of programs lack a formalized method to assess attending procedural competency. Further research is needed to determine the value and benefit of different methods available for procedural skill competency assessment. It is believed that preventing procedural skill decay in attending physicians by a standardized process has the potential to improve patient outcomes, reduce costs and complication rates, and improve physician self-esteem, well-being, and confidence.

Coupled Gluteus Maximus and Gluteus Medius Recruitment Patterns Modulate Hip Adduction Variability During Single-Limb Step-Downs: A Cross-Sectional Study.

CONTEXT: Examining the coordinated coupling of muscle recruitment patterns may provide insight into movement variability in sport-related tasks. OBJECTIVE: The purpose of this study was to examine the relationship between coupled gluteus maximus and medius recruitment patterns and hip-adduction variability during single-limb step-downs. DESIGN: Cross-sectional. SETTING: Biomechanics laboratory. PARTICIPANTS: Forty healthy adults, including 26 women and 14 men, mean age 23.8 (1.6) years, mean body mass index 24.2 (3.1) kg/m2, participated. INTERVENTIONS: Lower-extremity kinematics were acquired during 20 single-limb step-downs from a 19-cm step height. Electromyography (EMG) signals were captured with surface electrodes. Isometric hip-extension strength was obtained. MAIN OUTCOME MEASURES: Hip-adduction variability, measured as the SD of peak hip adduction across 20 repetitions of the step-down task, was measured. The mean amplitudes of gluteus maximus and gluteus medius EMG recruitment were examined. Determinism and entropy of the coupled EMG signals were computed with cross-recurrence quantification analyses. RESULTS: Hip-adduction variability correlated inversely with determinism (r = -.453, P = .018) and positively with entropy (r = .409, P = .034) in coupled gluteus maximus/medius recruitment patterns but not with hip-extensor strength nor with magnitudes of mean gluteus maximus or medius recruitment (r = -.003, .081, and .035; P = .990, .688, and .864, respectively). CONCLUSION: Hip-adduction variability during single-limb step-downs correlated more strongly with measures of coupled gluteus maximus and medius recruitment patterns than with hip-extensor strength or magnitudes of muscle recruitment. Examining coupled recruitment patterns may provide an alternative understanding of the extent to which hip neuromuscular control modulates lower-extremity kinematics beyond examining muscle strength or EMG recruitment magnitudes.

Hip extensor fatigue alters hip and knee coupling dynamics during single-limb step-downs: A randomized controlled trial.

Impaired hip muscle function may cause movement coordination deficits that increase lower extremity injury risks. We examined whether hip and knee coordination is altered during single-limb step-downs following a hip extensor fatigue protocol. Forty participants in this randomized controlled trial performed 20 single-limb step-downs before and after completing either a fatigue protocol or a sham fatigue protocol. Means and SDs of sagittal and frontal plane hip and knee kinematics were measured. Nonlinear measures of coupled hip and knee coordination were examined with cross recurrence quantification analyses. Pre- to post-fatigue change scores were analyzed inferentially (α = 0.05). The fatigue protocol induced 22.2% strength reduction in the fatigue group, versus 4% reduction in the sham group. Neither the magnitude nor variability in sagittal and frontal plane hip and knee kinematics changed following the fatigue protocol (P > .05, small effect sizes). Participants in the fatigue group, however, performed post-fatigue step-downs with greater cross determinism (P = .046, effect size = 0.71) and mean line (P = .038, effect size = 0.74) in sagittal plane hip and frontal plane knee coupling, whereas participants in the sham-control group performed step-downs with reductions in those measures. In the fatigued state, participants performed repeated step-downs with subtle increases in cross determinism and cross mean line, which implies they performed the task with greater predictability of hip and knee coupling and less adaptability. The findings may provide insight into coupled movement patterns and their reflection of motor control.

The Effects of Multi-Day vs. Single Pre-exercise Nitrate Supplement Dosing on Simulated Cycling Time Trial Performance and Skeletal Muscle Oxygenation.

Jo, E, Fischer, M, Auslander, AT, Beigarten, A, Daggy, B, Hansen, K, Kessler, L, Osmond, A, Wang, H, and Wes, R. The effects of multiday vs. single pre-exercise nitrate supplement dosing on simulated cycling time trial performance and skeletal muscle oxygenation. J Strength Cond Res 33(1): 217-224, 2019-A transient augmentation in the metabolic efficiency of skeletal muscle is the purported basis for dietary nitrate supplementation amongst competitive and recreational athletes alike. Previous studies support the ergogenic effects of nitrate supplementation, as findings indicated improved microvascular blood flow, exercise economy, and performance with relatively short-term supplementation. As with most ergogenic aids, the optimum duration of supplementation before performance or competition, i.e., loading phase, is a critical determinant for efficacy. Therefore, the purpose of this study was to investigate the effects of long-term vs. single dosing nitrate supplementation on skeletal muscle oxygenation and cycling performance. In a randomized, placebo controlled, double blind, parallel design study, healthy, recreationally active men (n = 15) and women (n = 14) subjects (age = 18-29 years) completed an 8 km (5 mi) simulated cycling time trial before and after a 14-day supplementation period with either a nitrate supplement (Multi-Day Dosing Group) (n = 14) or placebo (Single Pre-Exercise Dosing Group; SD) (n = 15). Both groups consumed a single dose of the nitrate supplement 2 hours before the post-treatment time trial. In addition, skeletal muscle oxygenation was measured via near-infrared spectroscopy during each time trial. Multiday nitrate supplementation significantly decreased time to completion (p = 0.01) and increased average power (p = 0.04) and speed (p = 0.02) from pre-to post-treatment, while a single dosing produced no significant changes to these measures. There were no significant differences over time and across treatments for any other measures including muscle oxygenation variables. Overall, long-term nitrate supplementation appears to have an advantage over a single pre-exercise dosing on cycling performance and metabolic efficiency as indicated by an increase in power output with no change in oxygenation.

Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection.

BACKGROUND: The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear. METHODS: In 14 U.S. hospitals with high adherence to quality measures for the treatment of pneumonia, we provided guidance for clinicians about national clinical practice recommendations for the treatment of lower respiratory tract infections and the interpretation of procalcitonin assays. We then randomly assigned patients who presented to the emergency department with a suspected lower respiratory tract infection and for whom the treating physician was uncertain whether antibiotic therapy was indicated to one of two groups: the procalcitonin group, in which the treating clinicians were provided with real-time initial (and serial, if the patient was hospitalized) procalcitonin assay results and an antibiotic use guideline with graded recommendations based on four tiers of procalcitonin levels, or the usual-care group. We hypothesized that within 30 days after enrollment the total antibiotic-days would be lower - and the percentage of patients with adverse outcomes would not be more than 4.5 percentage points higher - in the procalcitonin group than in the usual-care group. RESULTS: A total of 1656 patients were included in the final analysis cohort (826 randomly assigned to the procalcitonin group and 830 to the usual-care group), of whom 782 (47.2%) were hospitalized and 984 (59.4%) received antibiotics within 30 days. The treating clinician received procalcitonin assay results for 792 of 826 patients (95.9%) in the procalcitonin group (median time from sample collection to assay result, 77 minutes) and for 18 of 830 patients (2.2%) in the usual-care group. In both groups, the procalcitonin-level tier was associated with the decision to prescribe antibiotics in the emergency department. There was no significant difference between the procalcitonin group and the usual-care group in antibiotic-days (mean, 4.2 and 4.3 days, respectively; difference, -0.05 day; 95% confidence interval [CI], -0.6 to 0.5; P=0.87) or the proportion of patients with adverse outcomes (11.7% [96 patients] and 13.1% [109 patients]; difference, -1.5 percentage points; 95% CI, -4.6 to 1.7; P<0.001 for noninferiority) within 30 days. CONCLUSIONS: The provision of procalcitonin assay results, along with instructions on their interpretation, to emergency department and hospital-based clinicians did not result in less use of antibiotics than did usual care among patients with suspected lower respiratory tract infection. (Funded by the National Institute of General Medical Sciences; ProACT ClinicalTrials.gov number, NCT02130986 .).

Cost Savings and Patient Experiences of a Clinic-Based, Wide-Awake Hand Surgery Program at a Military Medical Center: A Critical Analysis of the First 100 Procedures.

PURPOSE: Wide-awake, local anesthesia, no tourniquet (WALANT) hand surgery was developed to improve access to hand surgery care while optimizing medical resources. Hand surgery in the clinic setting may result in substantial cost savings for the United States Military Health Care System (MHS) and provide a safe alternative to performing similar procedures in the operating room. METHODS: A prospective cohort study was performed on the first 100 consecutive clinic-based WALANT hand surgery procedures performed at a military medical center from January 2014 to September 2015 by a single hand surgeon. Cost savings analysis was performed by using the Medical Expense and Performance Reporting System, the standard cost accounting system for the MHS, to compare procedures performed in the clinic versus the operating room during the study period. A study specific questionnaire was obtained for 66 procedures to evaluate the patient's experience. RESULTS: For carpal tunnel release (n = 34) and A1 pulley release (n = 33), there were 85% and 70% cost savings by having the procedures performed in clinic under WALANT compared with the main operating room, respectively. During the study period, carpal tunnel release, A1 pulley release, and de Quervain release performed in the clinic instead of the operating room amounted to $393,100 in cost savings for the MHS. There were no adverse events during the WALANT procedure. CONCLUSIONS: A clinic-based WALANT hand surgery program at a military medical center results in considerable cost savings for the MHS. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis IV.

Implementation of TeamSTEPPS at a Level-1 Military Trauma Center: The San Antonio Military Medical Center Experience.

CONTEXT: When a health care system deals with complex trauma patients while simultaneously serving as an educational platform, teamwork and clear communication are imperative. While there are numerous tools and resources available to address the concerns surrounding patient safety, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) emphasizes a team approach to improve communication among all caregivers and is specifically designed to improve patient safety through improved communication. This article reports the interim results of implementation of TeamSTEPPS in the operating room environment at the most complex and busiest tertiary military trauma center in the Department of Defense in the midst of the longest period of continuous combat operations in US history. METHODS: Data were collected from December 2013 through March 2014 on the number of total cases performed by month, number of debrief surveys submitted for those months, and associated percentage of surveys completed based on case category. RESULTS: The overall compliance rate for the TeamSTEPPS process (from the pre-op brief to the debrief survey completion) was 75.1%. Responses showed a decrease in concerns in all areas during the period of observation. Equipment-related complaints decreased by 48%; instrument-related issues decreased by 29.9%; supply issues decreased by 53.3%; personnel issues decreased by 90.5%; case scheduling issues decreased by 35.7%; and preference card issues decreased by 72.1%. CONCLUSIONS: Our results demonstrate that TeamSTEPPS can be successfully implemented in an integrated level-1 trauma center in the midst of combat casualty care with a greater than 75% overall compliance with TeamSTEPPS briefs. Further study on the sustainability of these results and the effect on operating room safety, productivity, and efficiency is necessary.

A comparison of the high-affinity peripheral benzodiazepine receptor ligands DAA1106 and (R)-PK11195 in rat models of neuroinflammation: implications for PET imaging of microglial activation.

Activated microglia are an important feature of many neurological diseases and can be imaged in vivo using 1-(2-chlorophenyl)-N-methyl-N-(1-methylpropyl)-3-isoquinolinecarboxamide (PK11195), a ligand that binds the peripheral benzodiazepine receptor (PBR). N-(2,5-dimethoxybenzyl)-N-(5-fluoro-2-phenoxyphenyl) acetamide (DAA1106) is a new PBR-specific ligand that has been reported to bind to PBR with higher affinity compared with PK11195. We hypothesized that this high-affinity binding of DAA1106 to PBR will enable better delineation of microglia in vivo using positron emission tomography. [(3)H]DAA1106 showed higher binding affinity compared with [(3)H](R)-PK11195 in brain tissue derived from normal rats and the rats injected intrastriatally with 6-hydroxydopamine or lipopolysaccharide at the site of the lesion. Immunohistochemistry combined with autoradiography in brain tissues as well as correlation analyses showed that increased [(3)H]DAA1106 binding corresponded mainly to activated microglia. Finally, ex vivo autoradiography and positron emission tomography imaging in vivo showed greater retention of [(11)C]DAA1106 compared with [(11)C](R)-PK11195 in animals injected with either lipopolysaccaride or 6-hydroxydopamine at the site of lesion. These results indicate that DAA1106 binds with higher affinity to microglia in rat models of neuroinflammation when compared with PK11195, suggesting that [(11)C]DAA1106 may represent a significant improvement over [(11)C](R)-PK11195 for in vivo imaging of activated microglia in human neuroinflammatory disorders.

Gain sharing: a good concept getting a bad name?

The introduction of diagnosis-related groups (DRGs) created a clear misalignment between the incentives facing hospitals and those facing physicians. The interest in gain sharing that developed in the 1990s represented an attempt by physicians to extract and hospitals to offer some of the savings being produced by physicians. Advisory bulletins by the Office of Inspector General (Department of Health and Human Services) quickly put a stop to further interest in these strategies. Newer, narrowly defined types of gain sharing have been under consideration. More broadly defined strategies that will be tested under a new Centers for Medicare and Medicaid Services demonstration are more promising.