Comparative Effectiveness of Topically Administered Tranexamic Acid Versus Topical Oxymetazoline Spray for Achieving Hemostasis in Epistaxis.

BACKGROUND: The use of tranexamic acid (TXA) has recently gained popularity as a treatment modality for epistaxis in the emergency department. Previous studies have compared topical TXA to nasal packing. However, topical TXA has not yet been compared with topical oxymetazoline in the treatment of epistaxis. OBJECTIVES: This study compares the efficacy of the intravenous formulation of TXA applied topically vs. the vasoconstrictor oxymetazoline applied topically in achieving hemostasis in patients presenting to the emergency department with anterior epistaxis. METHODS: In this prospective study, patients presenting to the emergency department with the chief complaint of epistaxis, and meeting inclusion criteria, were allocated into 2 treatment groups; topical oxymetazoline vs. topical application of the intravenous preparation of TXA. Patients were assessed for time to hemostasis in the emergency department as well as the occurrence of rebleeding within the next 48 h after discharge. RESULTS: Hemostasis was achieved in 14 (78%) of the 18 patients in the TXA group compared with 7 (35%) of the 20 patients in the oxymetazoline group. While there were occurrences of rebleeding in the emergency department before discharge and at 48 h in both groups, 11 patients in the TXA group had no recurrence of bleeding compared with 5 in the oxymetazoline group. CONCLUSION: This study demonstrated that the topical application of the intravenous preparation of TXA is more effective than topical oxymetazoline for achievement of hemostasis in anterior epistaxis. This has clinical significance toward preventing an avoidable need for escalation of treatment that could include applying nasal packing or cautery as well as preventing avoidable return emergency department visits. These outcomes would increase cost, potentially increase patient discomfort, and prolong emergency department throughput time.

A study of time saved by emergency medicine physicians through working with clinical pharmacists in the emergency department.

PURPOSE: To describe quantitatively the impact on physician efficiency when an Emergency Medicine Clinical Pharmacist (EMCP) is available to Emergency Department (ED) physicians while working under a collaborative care agreement in a Michigan-based Health System. METHODS: Four EMCPs each logged and categorized their time during 14 ten hour shifts, for a total of 56 shifts or 560 total hours worked. There were nine categories observed including: culture call back, urine, blood, or other culture follow up, antibiotic changes, patient call-backs, pharmacy call backs, critically ill, and general questions. RESULTS: EMCPs saved ED physicians an average of 75 min per shift, with the highest yield categories being general questions (25.2 min per shift (mps), standard error (SE) = 2.67), critically ill patient service (11.5 mps, SE = 2.66), and urine culture follow-ups (11.3 mps, SE = 1.05). CONCLUSIONS: EMCPs in the ED save physicians a significant amount of time per shift, and categorically the most time saved was in fielding general questions, time spent with critically ill patients, and following up on urine cultures. The time saved by physicians could translate into more patients seen per shift.

Establishing a baseline for multilingual capabilities of medical students at the Michigan State University College of Osteopathic Medicine.

CONTEXT: The language proficiencies of Michigan State University College of Osteopathic Medicine (MSUCOM) medical students are unknown. As of 2015, approximately 8% (or roughly 25 million) of the US population over the age of five were considered "limited English proficient". Research indicates, however, that it is valuable to patients to be able to communicate in their primary language with their primary care physician. If medical students' language proficiencies were known, the medical school curriculum could be adapted to leverage or enhance a student's language proficiencies, preparing students to serve in communities where their patients language proficiencies align. OBJECTIVES: The aim of this pilot study was to survey MSUCOM medical students in order to assess their language proficiencies with two goals in mind: first, to develop medical school curriculum that would leverage student's language proficiencies, and second, to encourage student placement within diverse communities throughout the state of Michigan where these physicians-in-training speak or understand the primary language of the local community to better serve patients. METHODS: For this cross-sectional descriptive pilot study, a short, author-created survey was sent to 1,226 osteopathic medical students (OMS-I to OMS-IV) at MSUCOM. Participants were asked questions pertaining to language proficiency, number of languages spoken, prior exposure to education abroad, and demographic information. All participant data were only reported in grouped, collective, de-identified terms. Descriptive statistical analyses (frequencies, percentages) were calculated utilizing SPSS Version 25 software. RESULTS: Over the course of several months, 698 (58.7%) current MSUCOM medical students participated in the study. Of those students, 382 (54.7%) responded that they were multilingual. The top three second languages reported spoken were: English 332 (47.6%), Spanish 169 (24.2%), and Arabic 64 (9.2%). In addition, 249 (37.2%) said they had prior exposure to education abroad, and 177 (26.4%) said they had lived in another country for more than 6 months. CONCLUSIONS: The majority, 382 (54.7%), of the MSUCOM students who participated in the survey have some degree of multilingual capabilities. The student population at MSUCOM may benefit from completing primary care rotations in diverse communities within the state of Michigan. Likewise, the communities throughout Michigan may benefit from having bilingual and multilingual medical students serve in their medical facilities. Further research on the efficacy of leveraging language skills in various communities, as well as broadening the population sample, is warranted to refine and validate the observed pilot study results.

Exploring New Patient Understanding of Osteopathic Manipulative Medicine using a Cross-Sectional Survey and Mixed Methods Approach.

INTRODUCTION: Osteopathic manipulative medicine (OMM), a patient-focused approach to medical treatment utilized by doctors of osteopathic medicine (DO), continues to be an under-utilized resource in treating musculoskeletal disorders. Lack of familiarity by both referring physicians and patients of OMM can impact patient-physician communication and impede patient-centered care approaches. This 2020-2021 study was conducted to investigate new patient understanding of OMM within the Michigan State University OMM Clinic. METHODS: A set of 18 survey questions developed by the authors within their MSU OMM clinic were utilized for the study. The main purpose of the questions was to generally ascertain new patient's understanding of OMM, its role in patient care, who can place clinic referrals and the services an OMM clinic provides. Respondents were new adult patients at the MSU OMM clinic. RESULTS: The convenience study sample of 83 respondents was primarily female, 60 (72.3%). Few respondents were familiar with OMM, as only eight (9.64%) reported prior experience with OMM. Of the 83 patients in this study, 69 (80.7%) reported back pain. When examining referral patterns, there were low numbers of referrals from non-PCP providers, especially from advanced practice providers (APP), including physician assistants (n = three, 3.66%) and nurse practitioners (n = eight, 7.96%). Most surveyed patients 61 (73.5%) had been referred by their primary care providers. CONCLUSIONS: Results indicate that communication directed to non-DO physicians, advanced practice providers and patients about OMM services may be helpful to provide noninvasive symptomatic treatment options for musculoskeletal conditions. Further larger-scale studies examining both non-DO provider and new patient perceptions concerning OMM are clearly warranted.

Common Problematic Scholarly Activity Project Planning Expectations of Project Novices.

INTRODUCTION: Scholarly Activity (SA) projects, whether using methods more traditionally associated with research and or "quality improvement" projects, have been shown to confer value to resident physicians and other project novices in multiple ways. The inclusion of community and university-based residents and faculty in spearheading SA projects has led to improved understanding of medical literature and enhanced clinical practices, arguably producing more "well-rounded" physicians. PURPOSE OF PAPER: The primary purpose of this paper is to provide a summary of problematic expectations frequently assumed by project novices when developing and conducting SA projects. RESULTS: The authors will discuss a total of 26 problematic project-related novice expectations during five typical project phase categories. CONCLUSIONS: Learning to navigate the complexities of training to become a practicing physician, while also planning high quality SA project designs has been and will continue to be a complex challenge. The authors hope that this article can be used by supervising faculty and other graduate medical education mentors to assist the SA project novice (SAPN) plan SA projects. By establishing realistic expectations during project planning phases, the SAPN can avoid potential missteps that typically impede SA project completion.

Data on the hemostasis in epistaxis with Topically Administered TXA Versus Topical Oxymetazoline Spray.

The use of tranexamic acid (TXA) has recently gained popularity as a treatment modality for epistaxis in the emergency department. Data are presented on the efficacy of the topical use of the intravenous formulation of TXA versus the vasoconstrictor oxymetazoline applied topically in achieving hemostasis in patient presenting to the emergency department with anterior epistaxis. The original article "Comparative Effectiveness of Topically Administered TXA Versus Topical Oxymetazoline Spray for Achieving Hemostasis in Epistaxis" [1] provides complete interpretation of the data. The dataset regarding these treatment modalities has clinical significance toward preventing an avoidable need for escalation of treatment that could potentially increase patient discomfort and prolong emergency department throughput time.

An Evaluation of a Community Hospital's Emergency Department Ultrasonography Processes for the Diagnosis of Acute Pediatric Appendicitis.

CONTEXT: Since the 1980s, the use of ultrasonography for suspected acute pediatric appendicitis has become increasingly common. Multiple studies have suggested that ultrasound of the appendix has consistently high sensitivity and specificity when the appendix can be clearly visualized. The authors' primary objective for this study was to retrospectively evaluate their community-based healthcare system's processes for detecting acute pediatric appendicitis using ultrasonography. METHODS: This was a retrospective medical chart review study of data over a five-year 2014-2018 period at Mercy Health Muskegon in Muskegon, Michigan. All patients aged 3-18 years who had received an appendix ultrasound during this period were identified using the McKesson Radiology (MS) PACS-Lite computer program. Pediatric appendix ultrasound cases were collected and analyzed for sensitivity, specificity, positive predictive value, negative predictive value with 95% confidence intervals. Acute appendicitis cases had been confirmed based on pathology reports. Secondary measures including white blood cell, body mass index, and body temperature were also included in analyses. RESULTS: In this sample, the overall sensitivity at detecting acute pediatric appendicitis using ultrasonography was relatively low at approximately 42% (95% CI: 21.1 - 66.0%). On the other hand, sample specificity was quite high at 97% (95% CI: 89.9 - 99.5%). The overall positive predictive value (PPV) was 80% (95% CI: 44.2-96.5%) and the negative predictive Value (NPV) was 86% (95% CI: 75.7-92.4%). The occurrence for false positives was 20% (95% CI: 3.5-55.8%). False negatives were 14% (95% CI: 7.6-24.3%). CONCLUSIONS: The use of ultrasonography at the authors' institution less often accurately identified cases of later-confirmed pediatric appendicitis compared to some earlier published studies. The authors concluded that this could be due to seeing a lower number of more complex/ambiguous cases of pediatric appendicitis or lack of hospital personnel's pediatric-specific training and/or experience compared to specialty children's hospitals. It is possible that imaging improvements could be achieved by either or a combination of: offering training sessions for general ultrasound technicians, offering training session for radiologists, and visiting pediatric physicians and ultrasound technicians. A valuable follow-up study would be to track anticipated improvements and lead to formulation of an acute pediatric appendicitis care protocol within the authors' healthcare system.

Sub-Dissociative Ketamine Use in the Emergency Department for Treatment of Suspected Acute Nephrolithiasis: The SKANS Study.

CONTEXT: Currently, there is no standard therapy for treatment of acute renal colic. With the increased scrutiny and controversy now surrounding opioids, the authors identified a need to investigate an alternative medication for pain control. As such, they sought to determine the efficacy of sub-dissociative (i.e., low) doses (0.3 mg/kg) of ketamine in providing Emergency Department (ED) patients acute pain management for renal colic secondary to nephrolithiasis. METHODS: After institutional review board (IRB) approval, the authors conducted a non-blinded, prospective clinical study. A convenience sample of n = 34 patients from the ED of a Western Michigan-based health system with suspected renal colic received one intravenous dose of ketorolac, 30 mg if over 50 kg body weight or 15 mg if under 50 kg In patients weighing greater than 50 kg, up to two doses of sub-dissociative ketamine were then given to further control pain. Pain was assessed at times 0, 30, 60, 90 and 120 minutes. RESULTS: There was a statistically significant pain reduction with administration of sub-dissociative ketamine, with 24 (69.2%) patients reporting an average reduction in pain score > 30% (t = 3.16, p = 0.004). Initial average pain scores for patients receiving sub-dissociative ketamine averaged 7.76 (SD = 2.55) on the 11-point verbal Pain Numeric Rating Scale. After a first dose of ketamine, patients' average pain score was 3.56 (SD = 0.74) at 30 minutes. After two hours, patients' average score was 2.56 (SD = 0.65), indicating that pain control was still effective over time with no statistically significant change in pain scores. Additionally, there was no statistically significant difference in pain reduction observed between genders (t = -0.192, p = 0.850). CONCLUSIONS: Based on these results, sub-dissociative ketamine may be considered a reasonable and effective supplemental non-opiate treatment option for suspected renal colic in otherwise healthy 18-70-year-old patients and could provide an effective alternative to traditional therapies. Further studies utilizing this methodology with larger, more generalizable samples are needed to further validate these findings.

Ensuring Patient Safety in Emergency Peripheral Ultrasound-Guided Nerve Blocks: An Evaluation of a Quality Improvement/Patient Safety Initiative.

CONTEXT: During the past two decades, bedside ultrasound has revolutionized the practice of emergency medicine. Physicians are now expected to be competent in utilizing ultrasound skills, for patients presenting with conditions ranging from trauma to skin evaluations. The overall purpose of this quality improvement/patient safety (QIPS) project was to evaluate the effectiveness of a pair of five-hour, hands-on didactic/training sessions, aimed at preparing a sample of emergency medicine physicians, residents and medical students to perform peripheral ultrasound-guided nerve blocks. METHODS: The study location was set in a community-based emergency medicine program in Pontiac, Michigan. Data was collected from N = 54 emergency medicine residents, physicians and medical students. Data was collected from two training sessions in November 2017 and January 2018. The training consisted of a 12-question pre-test, followed by five hours of hands on & didactic training, with a subsequent post-test containing the same questions. RESULTS: The authors compiled the data from both training sessions and found that the participants had an average correct percentage of 5.52 of 12 (46%) on the pre-test. After attending the training session, participants had an overall correct percentage of 9.24 of 12 (77%) on the post-test. This pre-to post-training increase of the mean scores was statistically significant, t (53) = -10.76 (p < 0.01), with an effect size (Cohen's d) of 1.82. Post hoc power calculations utilizing the d = 1.82 effect size revealed statistical power (1- ß) of 100%. CONCLUSIONS: The results of this QIPS evaluation project suggest that emergency physicians, residents and medical students may achieve an improved understanding of key ultrasound-guided nerve block material after a single five-hour session of hands-on training and didactics. Going forward, additional studies employing larger sample sizes that allow for outcome stratification by group (emergency physicians, residents, or medical students) along with relevant demographic variables (age, years in practice, etc.) in similar settings are needed to further verify these findings.

Radiation Dose Reduction of Computed Tomography in Complex Distal Femur Fractures: A Cadaver Study to Develop a Low Dose Scanning Protocol.

CONTEXT: Recent advances in diagnostic imaging have made computed tomography (CT) a widely used test in trauma patients. Consequently, the collective radiation burdened sustained by this patient population has increased substantially. The purpose of this cadaveric study was to determine if a significantly lowered CT radiation dose protocol would provide adequate imaging studies for the surgeon, using the distal femur as a model. METHODS: Ten adult cadaveric knee specimens were used to create Orthopaedic Trauma Association (AO/OTA) 33-C3 distal femur fractures with associated coronal plane Hoffa fractures and varying intra-articular displacements. Using a single CT scanner, each cadaver was scanned at 5 separate protocols defined by sequentially lowered radiation doses, the highest of which was one-third the value of our institution's current protocol. These images were then evaluated by fellowship-trained orthopedic surgeons, an orthopedic trauma fellow, and residents. Observer reliability and confidence levels were calculated for measuring fracture displacement, assessing the quality of 3D reconstructions, and developing treatment plans. RESULTS: Across all reviewers and specimens, there was an average difference of 0.66 millimeters (mm) between the measured fracture gap and true fracture gap. The highest intraclass correlation coefficient (ICC) calculated for the inter-rater reliability of gap measurements was 0.983 at 75 mAs (95% CI: 0.955-0.996), followed by 0.973 (95% CI: 0.930-0.993) and 0.958 (95% CI: 0.896-0.988) at 15 mAs and 60 mAs, respectively. All 3D reconstructions obtained at 75 mAs and 45 mAs values (N = 8) were of acceptable imaging quality to all reviewers, while only 3 of 4 3D reconstructions obtained at 15 mAs were considered acceptable. There was no difference in treatment plans across all reviewers, regardless of radiation dose. CONCLUSIONS: In summary, our results indicate that CT scans of complex distal femur fractures at one-third the amount of radiation exposure may provide adequate imaging necessary to develop an appropriate treatment plan. At significantly lowered doses, the reviewers were able to accurately measure the amount of fracture displacement and identify the presence of each Hoffa fracture. Future studies are necessary to compare this protocol's diagnostic capacity and limitations in evaluating complex fractures with that of our institution's standard protocol in a clinical setting.

Do Not Let it Be the Last: End-of-Life Care Decisions in the Primary Care Clinic.

CONTEXT: For many patients, end-of-life care (EOLC) wishes are unknown and are generally only brought up during healthcare crises. During such healthcare episodes, loved ones are often distraught, and as such, can find it difficult to focus on details surrounding the event. The best place for these discussions may be in non-acute settings including primary care clinics. The purpose of this study was to examine how well a sample of patients (N = 177) in three Michigan-based primary care teaching clinics thought they and their loved ones were prepared in terms of having their EOLC wishes known. METHODS: Prospective data were collected from three Internal Medicine teaching clinics in the Metro-Detroit area through an anonymous written survey addressing EOLC issues in a 16-item cross-sectional study. Respondents were adult patients at one of three participating primary care clinics. Perceived preparedness for EOLC was measured by: 1) possibly having had a prior EOLC discussion with a healthcare provider 2) having created an Advance Directive, such as a Durable Power of Attorney (DPOA) or Living Will with medical decision preferences, 3) reported preferences for quality versus quantity of life, and 4) preferences for CPR and other specific life-sustaining interventions. RESULTS: In this sample, 77 (43.5%) of 177 respondents had discussed their EOLC wishes with a provider. Regarding Advance Directives, 63/177 (35.6%) had established a DPOA, and 59/177 (22%) had made a Living Will. The majority of respondents preferred quality over quantity of life. The most difficult EOLC questions included the decision for CPR, tracheostomy, and PEG tube placement. CONCLUSIONS: Based on these results, EOLC discussions probably occur infrequently in the primary care or other healthcare settings. Most survey responses indicated that sample patients were unprepared concerning the details of future EOLC decisions. Engagement of such discussions should be a part of routine visits in the primary care clinic and should be re-visited when there is a change in a patient's health. Further larger-scale studies using validated surveys are required in this vitally important area of practice. Key Words: advance care planning, end-of-life care conversations, primary care.

Chief Resident Skills: A Study on Resident Perceptions of Skill Importance and Confidence.

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.

How automatic notification of infectious disease specialists impacted the management of Staphylococcus aureus bacteremia in a community hospital setting.

Objective: The objective of this study was to review the impact of an automatic email notification to infectious disease consultants. Design: Cases were identified from a community hospital system microbiology database by at least one positive blood culture. Records were reviewed both before (2013 and 2014) and after (2015 and 2016) the implementation of the automated email system (intervention). Prior to this policy, consultation with the infectious disease (ID) specialist was at the discretion of the primary team. Results: There were no significant differences in 30-day mortality between the two groups (18 vs 20%, p = 0.10). However, a trend of shorter hospital stays (12.2 vs 9.5 days, p = 0.03) and reduced 30 day readmissions (40% vs 19%, p = 0.03) was observed and antibiotics prescribed for complicated cases was more appropriate (57% vs 85%, p = 0.004). Conclusions: In this study population, the implementation of an automatic email generator to ID specialists was associated with a shorter hospital length of stay, less 30-day readmissions and more appropriate length of antibiotics prescribed in complicated cases of SAB. The authors recommend future studies replicating the methodology employed here with larger sample sizes before consideration of employing a similar automatic email ID consult generation at other health systems.

Correlation of Clinical Factors and Audiometric Characteristics with MRI Findings in Patients with Asymmetric Sensorineural Hearing Loss.

CONTEXT: To identify the presence of any correlative factors between presenting symptoms and characteristics of asymmetrical sensorineural hearing loss on audiogram, and if retrocochlear pathology was identified on MRI in patients presenting in a private practice setting. METHODS: A retrospective study of patients meeting inclusion criteria who underwent MRI for asymmetric hearing loss between March 2014 to March 2017 was reviewed using Allscripts electronic health records. This data was then compiled in an excel spreadsheet and submitted for statistical analysis. RESULTS: Of the initial 687 study patients, N = 303 patients met the inclusion criteria for review. Of these 303, 48 patients (15.8%) had abnormal MRI findings. Chi-square analysis performed showed no significant association of varied clinical variables (e.g. uni and bi-lateral tinnitus, vertigo, etc.) with abnormal MRI. Point Biserial Correlation analysis revealed no statistically significant correlations, with the exception of that between AS (Left Ear) 6 kHz and MRI lesions (r = -0.115, p = 0.045). Logistic and multinomial logistic regression analysis used to calculate odds ratios showed that for patients with hearing loss at the 6 kHz (dB) level, there is a very slightly lower, statistically significant likelihood of lesions showing up on MRI (OR, 0.984 (95% CI, 0.970-0.998), p = 0.0251). CONCLUSIONS: The results lead to the conclusion that there may be an association between experiencing hearing loss at the level of 6 kHz and a slightly lower chance of the presence of retrocochlear lesion noted on MRI.