Relationship between individual and country-level socio-economic background, USMLE step scores, and demographics of international medical graduates and residency match results.

PURPOSE: Twenty five percent of practicing physicians in the US are International Medical Graduates (IMGs) - physicians who completed their medical school training outside of the United States and Canada. There are multiple studies demonstrating higher socio-economic background is associated with medical school matriculation in the US. However, despite a substantial prevalence of IMGs in the American healthcare system, studies of the association between demographics, socio-economic background, and securing a residency position in the match are lacking. METHODS: We created a survey with questions on residency match-related data and information on personal socio-economic background. An invitation to participate in the study was sent to all IMGs that applied to the included residency programs after the conclusion of the 2022 residency match. We used multivariable logistic regression to compare survey responses to the odds of securing a residency match. RESULTS: The total number of survey respondents was 744 (response rate 15.1%). We found that younger age, higher United States Medical License Examination (USMLE) scores, higher-income country of origin (including the United States), fewer match attempts, applying to fewer specialties, having parents with college degree or higher, and coming from higher-than-average or lower-than-average family income were independently associated with increased odds of matching. Gender, personal income, and visa status did not demonstrate significant associations with residency match. CONCLUSIONS: Residency match is a significant expense for IMGs, especially for those from lower-income countries. International applicants from higher socio-economic backgrounds might have advantages in securing medical residency positions in the United States when controlling for other variables.

Comparison of clinical note quality between an automated digital intake tool and the standard note in the emergency department.

BACKGROUND: Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians. METHODS: Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa. RESULTS: A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49-0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4-66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49-0.60). The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified. CONCLUSION: Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.

High-Sensitivity Troponin T Testing for Pediatric Patients in the Emergency Department.

Debate exists on the usefulness of high-sensitivity cardiac troponin (hs-cTn) testing in pediatric patients due to the perceived low incidence of myocardial injury and lack of data concerning its efficacy. We evaluated the contribution of an increased hs-cTnT above the 99th percentile upper-reference limit (URL) to clinical diagnoses made in pediatric patients presenting to the emergency department (ED). Retrospective cohort study including patients aged 0-18 years presenting to the ED from 2018 to 2020 where hs-cTnT was measured. Sex-specific 99th percentile URLs of 15 and 10 ng/L for males and females, respectively, were used, with concentrations above these thresholds considered indicative of myocardial injury. Overall, 356 patients were identified in whom hs-cTnT concentrations were measured during ED clinical evaluation. Hs-cTnT was increased above the 99th percentile on presentation in 36 patients (10.1%). Twelve patients (3.4%) had a clinical cardiac diagnosis made. Hs-cTnT was increased in 6 of these (50.0%). Serial hs-cTnT from 106 patients with an initial hs-cTnT < 99th percentile was subsequently elevated in 5 (4.6%); none of whom had a final clinical cardiac diagnosis. Hs-cTnT has high specificity, but low sensitivity when used as a screening tool for myocardial injury when the gold standard is mostly clinical assessment. In present practice, however, they do not appear to track well with clinical diagnoses. Further studies are needed to more clearly define the role of hs-cTnT in this patient population.

Intranasal ketamine for acute pain management in children: A systematic review and meta-analysis.

STUDY OBJECTIVE: To assess the efficacy and safety of intranasal analgesic-dose ketamine as compared to intranasal fentanyl for pediatric acute pain. METHODS: A systematic review and meta-analysis was performed following the PRISMA guidelines. We searched PubMed, Embase, and Scopus databases for randomized controlled trials from inception to December 2019. We conducted meta-analysis with random-effects models to evaluate pain reduction, rescue analgesia, adverse events and sedation between intranasal ketamine and intranasal fentanyl. Random-effects models were used to estimate weighted mean differences (WMD) and pooled relative risks (RR). RESULTS: A total of 546 studies were screened and 4 trials were included. In the meta-analysis of 4 studies including 276 patients, ketamine had similar reductions in pain scores from baseline to all post-intervention times (10 to 15 min: WMD -1.42, 95% CI -9.95 to 7.10; 30 min: WMD 0.40, 95% CI -6.29 to 7.10; 60 min: WMD -0.64, 95% CI -6.76 to 5.47). Ketamine was associated with similar rates of rescue analgesia (RR 0.74, 95% CI 0.44 to 1.25). Ketamine had a higher risk of non-serious adverse events (RR 2.00, 95% CI 1.43 to 2.79), and no patients receiving ketamine had a serious adverse event. There was one serious adverse event (hypotension) with fentanyl that self-resolved. No patients receiving either IN fentanyl or ketamine had significant sedation. CONCLUSION: Intranasal analgesic-dose ketamine may be considered as an alternative to opioids for acute pain management in children. Its accepted use will depend on the tolerability of non-serious adverse events and the desire to avoid opioids.

What is the effect of a decision aid in potentially vulnerable parents? Insights from the head CT choice randomized trial.

OBJECTIVE: To test the hypotheses that use of the Head CT Choice decision aid would be similarly effective in all parent/patient dyads but parents with high (vs low) numeracy experience a greater increase in knowledge while those with low (vs high) health literacy experience a greater increase in trust. METHODS: This was a secondary analysis of a cluster randomized trial conducted at seven sites. One hundred seventy-two clinicians caring for 971 children at intermediate risk for clinically important traumatic brain injuries were randomized to shared decision making facilitated by the DA (n = 493) or to usual care (n = 478). We assessed for subgroup effects based on patient and parent characteristics, including socioeconomic status (health literacy, numeracy and income). We tested for interactions using regression models with indicators for arm assignment and study site. RESULTS: The decision aid did not increase knowledge more in parents with high numeracy (P for interaction [Pint ] = 0.14) or physician trust more in parents with low health literacy (Pint  = 0.34). The decision aid decreased decisional conflict more in non-white parents (decisional conflict scale, -8.14, 95% CI: -12.33 to -3.95; Pint  = 0.05) and increased physician trust more in socioeconomically disadvantaged parents (trust in physician scale, OR: 8.59, 95% CI: 2.35-14.83; Pint  = 0.04). CONCLUSIONS: Use of the Head CT Choice decision aid resulted in less decisional conflict in non-white parents and greater physician trust in socioeconomically disadvantaged parents. Decision aids may be particularly effective in potentially vulnerable parents.

Acute hemorrhagic edema of infancy and common mimics.

Acute hemorrhagic edema of infancy (AHEI) is a rare acute benign cutaneous leukocytoclastic vasculitis affecting children younger than 24 months of age. Its presentation can be confused with those of urticaria, erythema multiforme, Henoch-Schönlein purpura, idiopathic thrombocytopenia,meningococcemia, Kawasaki disease, and drug rash. We present 2 cases of acute hemorrhagic edema of infancy, discuss the characteristics of AHEI, and compare and contrast AHEI with similar dermatologic presentations. This review provides emergency physicians with the basic knowledge necessary to easily recognize AHEI as a distinct clinical entity. The patients were 19- and 23-month-old females who presented to the pediatric emergency department at St Mary's Hospital,Mayo Clinic in Rochester, Minnesota, with impressive purpuric rashes and edema of the hands and feet after preceding upper respiratory tract infections. Both children had benign courses with complete resolution of clinical findings. These 2 cases typify the presentation of AHEI.Acute hemorrhagic edema of infancy presents with characteristic purpuric lesions and extremity edema. The emergency physician's recognition of these presenting characteristics will help diagnose AHEI, avoid unnecessary procedures and tests, and aid in counseling the patient's parents.

Evaluation of Hematochezia in a Two-Day-Old Infant.

BACKGROUND: Hematochezia in the pediatric population, particularly infants, has a wide differential diagnosis ranging from benign to life-threatening causes. Obtaining a thorough history and identifying risk factors for more ominous disease is vital during the emergency department (ED) evaluation. CASE REPORT: The patient is a 2-day-old female who presented to the ED with 8-10 episodes of bright red blood in her stools. She was otherwise asymptomatic, with an uncomplicated pregnancy and delivery. Her history was significant for a sibling who recently tested positive for Escherichia coli O157:H7 in his stool and a family history of lactose intolerance. She was exclusively formula fed. An abdominal plain film was obtained and was normal. Milk protein enterocolitis was suspected and she was transitioned to hydrolyzed formula with resolution of her symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As emergency physicians, we need to be aware of the life-threatening conditions that are associated with hematochezia, such as necrotizing enterocolitis, and act quickly. However, many patients will have benign conditions, and recognizing the key historical and diagnostic pieces of the infant's presentation will prevent unnecessary evaluations and consultations.

Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes.

BACKGROUND: Ultrasonography is considered the most appropriate initial imaging study in the evaluation of acute appendicitis in children but has recently come under criticism with reports of low specificity and high indeterminate study rates, particularly when used in obese patients and patients early in the course of their disease, or when performed by sonographers with limited experience. OBJECTIVE: To (1) assess the impact of patient factors (gender, age, body mass index, and symptom duration) and system factors (call status or year of exam) on pediatric appendiceal US accuracy and indeterminate study rate, (2) assess the impact of indeterminate study results on follow-up CT and negative laparotomy rates and (3) present strategies to reduce the rate of indeterminate US studies and improve accuracy. MATERIALS AND METHODS: We retrospectively reviewed all US reports performed for the assessment of acute appendicitis in children <18 years old at Mayo Clinic Rochester from January 2010 to June 2014. RESULTS: A total of 790 US examinations were performed in 452 girls (57%) and 338 boys (43%). The prevalence of appendicitis was 18.5% (146/790). There were 109 true-positive, 440 true-negative, 17 false-positive, 6 false-negative, 218 equivocal and 41 technically inadequate US studies. A definitive interpretation was made in 72% of the studies, with an accuracy, sensitivity and specificity of 0.960, 0.948 and 0.963, respectively. No patient or system factors significantly affected US accuracy. Indeterminate studies (28%) had significantly higher CT utilization (46% vs. 11%) and normal appendectomy rates (6.9% vs. 3.5%). CONCLUSION: US should be the initial imaging study of choice for pediatric appendicitis. When a definitive interpretation was given, the accuracy was 96%, was independent of patient and system factors and resulted in reduced follow-up CTs and negative laparotomies. Accuracy can be increased by requiring the presence of periappendiceal inflammatory changes prior to interpreting a mildly distended appendix as positive for acute appendicitis. The indeterminate study rate can be reduced by not requiring visualization of the normal appendix for the exclusion of acute appendicitis.

Recurrent severe abdominal pain in the pediatric patient.

BACKGROUND: Ureteropelvic junction obstruction (UPJO) is a blockage occurring at the junction of the ureter and the renal pelvis. Pediatric patients with UPJO pose a diagnostic challenge when they present to the emergency department (ED) with severe recurrent abdominal pain if there is not a level of suspicion for this condition. OBJECTIVES: Our aim was to review presentation of UPJO to the ED, methods of diagnosis, and treatment of this common but often overlooked condition. CASE REPORT: We report on 2 patients, a 9-year-old and 3-year-old, who had multiple presentations to health care providers and the ED with intermittent and recurrent abdominal pain. Subsequent testing, including ultrasound (US) and computed tomography (CT) with diuretic-recreated symptoms, revealed UPJO. Open pyeloplasty was performed, resulting in complete resolution of symptoms. CONCLUSIONS: UPJO is an important diagnosis to consider when patients present to the ED with recurrent abdominal pain. US can be helpful in suspecting the diagnosis, but often CT, magnetic resonance urography, or diuretic scintigraphy is required for confirmation. Diuretics can be used to aid diagnostic testing by reproducing abdominal pain at the time of imaging. Referral to a urologist for open pyeloplasty is definitive treatment for this condition.

A review of medical malpractice cases involving trainees in the emergency department.

Background: This study characterizes medical malpractice lawsuits involving trainees providing care in the emergency department (ED), affording insight into the types of patients involved, clinical scenarios, and legal outcomes of these cases. Methods: Cases were identified using the legal database, Westlaw. Per chart review methods, relevant information was abstracted by 2 trained reviewers onto a standardized data abstraction form, with a senior author arbitrating disagreements. Results: We identified 60 cases reported between 1982 and 2017 in which a trainee was named in a lawsuit related to patient care provided in the ED. The most common alleged errors included diagnostic (n = 37, 61%), treatment (n = 13, 21%), and procedural errors (n = 19, 16%). In 21 cases (35%), it was alleged that no attending physician was directly involved in the care at any time. The attending was noted to have seen the patient in person at any point in only 11 total cases (18%). Of the 50 cases with known outcomes, 15 (30%) decided in favor of the patient, 21 (42%) were resolved in the physician's favor, and 14 (28%) were settled. Conclusion: This study underscores that trainees are vulnerable to malpractice cases and that lack of direct supervision is a prominent theme in these cases. This information suggests areas for further work and may help training programs, trainees, and supervising physicians design their practice patterns in ways that mitigate these risks in the future.

Descriptive Analysis of Components of Emergency Medicine Residency Program Websites.

INTRODUCTION: Most emergency medicine (EM) applicants use the internet as a source of information when evaluating residency programs. Previous studies have analyzed the components of residency program websites; however, there is a paucity of information regarding EM program websites. The purpose of our study was to analyze information on EM residency program websites. METHODS: In April-May 2020, we evaluated 249 United States EM residency program websites for presence or absence of 38 items relevant to EM applicants. Descriptive statistics were performed, including means and standard deviations. RESULTS: Of the 249 EM websites evaluated, the websites contained a mean of 20 of 38 items (53%). Only 16 programs (6%) contained at least three-quarters of the items of interest, and no programs contained all 38 items. The general categories with the least amount of items were social media use (9%), research (46%), and lifestyle (49%), compared to the other general categories such as application process (58%), resident information (63%), general program information (67%), and facility information (69%). The items provided by programs most often included program description (98%), blocks and rotations (91%), and faculty listing (88%). The items provided least often included housing/neighborhood information (17%) and social media links (19%). CONCLUSION: Our comprehensive review of EM residency websites in the US revealed the absence of many variables on most programs' websites. Use of this information to enhance accessibility of desired information stands to benefit both applicants and programs in the increasingly competitive specialty of EM.

Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma: A Cluster Randomized Trial.

Importance: The Pediatric Emergency Care Applied Research Network prediction rules for minor head trauma identify children at very low, intermediate, and high risk of clinically important traumatic brain injuries (ciTBIs) and recommend no computed tomography (CT) for those at very low risk. However, the prediction rules provide little guidance in the choice of home observation or CT in children at intermediate risk for ciTBI. Objective: To compare a decision aid with usual care in parents of children at intermediate risk for ciTBI. Design, Settings, and Participants: This cluster randomized trial was conducted in 7 geographically diverse US emergency departments (EDs) from April 1, 2014, to September 30, 2016. Eligible participants were emergency clinicians, children ages 2 to 18 years with minor head trauma at intermediate risk for ciTBI, and their parents. Interventions: Clinicians were randomly assigned (1:1 ratio) to shared decision-making facilitated by the Head CT Choice decision aid or to usual care. Main Outcomes and Measures: The primary outcome, selected by parent stakeholders, was knowledge of their child's risk for ciTBI and the available diagnostic options. Secondary outcomes included decisional conflict, parental involvement in decision-making, the ED CT rate, 7-day health care utilization, and missed ciTBI. Results: A total of 172 clinicians caring for 971 children (493 decision aid; 478 usual care) with minor head trauma at intermediate risk for ciTBI were enrolled. The patient mean (SD) age was 6.7 (7.1) years, 575 (59%) were male, and 253 (26%) were of nonwhite race. Parents in the decision aid arm compared with the usual care arm had greater knowledge (mean [SD] questions correct: 6.2 [2.0] vs 5.3 [2.0]; mean difference, 0.9; 95% CI, 0.6-1.3), had less decisional conflict (mean [SD] decisional conflict score, 14.8 [15.5] vs 19.2 [16.6]; mean difference, -4.4; 95% CI, -7.3 to -2.4), and were more involved in CT decision-making (observing patient involvement [OPTION] scores: mean [SD], 25.0 [8.5] vs 13.3 [6.5]; mean difference, 11.7; 95% CI, 9.6-13.9). Although the ED CT rate did not significantly differ (decision aid, 22% vs usual care, 24%; odds ratio, 0.81; 95% CI, 0.51-1.27), the mean number of imaging tests was lower in the decision aid arm 7 days after injury. No child had a missed ciTBI. Conclusions and Relevance: Use of a decision aid in parents of children at intermediate risk of ciTBI increased parent knowledge, decreased decisional conflict, and increased involvement in decision-making. The intervention did not significantly reduce the ED CT rate but safely decreased health care utilization 7 days after injury. Trial Registration: ClinicalTrials.gov Identifier: NCT02063087.

Surgical pathology of the ascending aorta: a clinicopathologic study of 513 cases.

Only 2 comprehensive surgical series, published in 1977 and 1983, have evaluated clinicopathologic features of the ascending aorta. Retrospective review of medical records and microscopic slides was performed on 513 consecutive patients with surgical resection of ascending aortic tissue (1985 to 1999). Patients were 2 to 89 years old (mean 59 y), and 303 (59%) were men. Aneurysm or dissection was the indication for surgery in 479. Aortic valves were also excised in 360. Systemic hypertension was present in 279, inherited connective tissue disease (ICTD) in 67, arteritis in 33, and acquired connective tissue disease in 16. Microscopy showed cystic medial degeneration (CMD) in 209, aortic dissection (AD) in 109 (with CMD in 56), normal media in 90, aortitis in 57 (with CMD in 14), and other findings in 48. The most significant, independent risk factor of CMD and AD was ICTD (confidence interval=7.61 and 2.26, respectively). Systemic hypertension was more common in patients with AD than without (P=0.0202). Normal media was the most common histologic finding associated with bicuspid aortic valve (P<0.0001). Among 57 patients with aortitis (giant cell in 39), ages ranged from 16 to 85 years (mean 64 y), and 42 (74%) were women; only 8 had Takayasu arteritis, and 11 had temporal or systemic arteritis. In surgically resected ascending aorta, the 3 most common histologic findings were CMD, AD, and normal media. ICTD, systemic hypertension, and bicuspid aortic valve were common comorbid findings. Giant cell aortitis occured predominantly in women, usually without systemic disease.

Unsuspected neonatal killers in emergency medicine.

A neonate presenting to the emergency department can present a challenge to even the most experienced clinician. This article has focused on four deceiving and potentially devastating neonatal diseases. 1. Neonatal herpes is a potentially devastating illness without pathognomonic signs or symptoms. Early recognition and therapy can reduce mortality markedly. Although no specific sign or symptom is diagnostic,the diagnosis should be strongly considered in the presence of HSV risk factors, atypical sepsis, unexplained acute hepatitis, or focal seizure activity. Acyclovir therapy should be initiated before viral dissemination or significant CNS replication occurs. 2. Pertussis is a disease in which infants are at greatest risk of death or severe complication. Neonatal pertussis often presents in an atypical manner, lacking the classic signs and symptoms such as the "whoop."More common signs and symptoms include cough, feeding difficulty,low-grade fever, emesis, increasing respiratory distress, apnea, cyanosis,and seizures. Management should include hospitalization, supportive care, and antibiotics. 3. Congenital heart defects, particularly ductal-dependent lesions, may have an initial asymptomatic period that culminates in a rapidly progressive and fatal course. A neonate with CHD presents with shock refractory to volume resuscitation or pressor support. Resuscitative efforts are ineffective unless PGE, is administered. 4. Inborn errors of metabolism often are unsuspected because of their protean and heterogeneous nature. Signs and symptoms are subtle,are nonspecific, and often mimic other, more common diseases.An elevated index of suspicion, along with application and correct interpretation of a select few laboratory tests, is the key to making a diagnosis. Therapy is relatively straightforward and focused on resuscitation followed by prevention of catabolism and correction of specifically identified abnormalities. Although these disorders are relatively uncommon, prompt diagnosis and therapy can lead to a decrease in morbidity and mortality. The key is to maintain a high index of suspicion.

A simple algorithm reduces computed tomography use in the diagnosis of appendicitis in children.

BACKGROUND: A diagnostic algorithm for appendicitis in children was created to reduce computed tomography (CT) use owing to the risk of cancer from radiation exposure and cost of CT. This study evaluates the impact of the algorithm on CT use and diagnostic accuracy of appendicitis. METHODS: Patients ≤18 years who underwent appendectomy for suspected appendicitis after presenting to the emergency department for 2 years before and 3 years after algorithm implementation were identified. Clinical characteristics and outcomes, including use of CT and negative appendectomy rate, were compared between the pre- and post-implementation periods. Multivariable analysis was used to determine the impact of CT on negative appendectomy. RESULTS: We identified 331 patients-41% in the pre- and 59% in the post-implementation period. CT utilization decreased from 39% to 18% (P < .001) after implementation. The negative appendectomy rate increased from 9% to 11% (P = .59). Use of CT did not impact the risk of negative appendectomy (P = .64). CONCLUSION: Utilization of CT was significantly reduced after implementation of a diagnostic algorithm for appendicitis without impacting diagnostic accuracy. Given the concern for increased risk of cancer after CT, these results support use of an algorithm in children with suspected appendicitis.