Novel use of ultrasound-guided transgluteal sciatic nerve block to treat severe herpes zoster pain along the S1 dermatome.

Patients presenting with herpes zoster (HZ) to emergency departments (EDs) across the United States represent a significant number of visits and have pain that is difficult to manage, sometimes even requiring opioid medications for adequate analgesia. Ultrasound-guided nerve blocks (UGNBs) are becoming more integrated into the ED physician's tool box for a multimodal approach to analgesia in various indications. Here we describe a novel use of the transgluteal sciatic UGNB for treatment of HZ pain along the S1 dermatome. A 48-year-old woman presented to the ED with right-sided leg pain associated with a HZ rash. After initially failing non-opioid pain management, the ED physician performed a transgluteal sciatic UGNB for our patient, leading to successful complete resolution of her pain, with no adverse effects reported. Our case highlights the potential role of using the transgluteal sciatic UGNB for analgesia related to HZ-related pain, as well as its potential opioid-sparing benefits. Although UGNBs require a baseline understanding of ultrasound technique for procedural guidance, this skillset has recently been incorporated as core competency within emergency medicine training in the United States. UGNBs should therefore be considered in the multimodal analgesic armamentarium for the ED treatment of HZ pain.

Trends in U.S. MD-PhD Program Matriculant Diversity by Sex and Race/Ethnicity.

PURPOSE: To examine demographic characteristics of matriculants to U.S. MD-PhD programs by sex and race/ethnicity from academic years (AYs) 2009-2018 and explore the relationships between trends in the percentage of female and underrepresented minority (URM) matriculants to programs with and without Medical Scientist Training Program (MSTP) funding. METHOD: Linear regression and time trend analysis of the absolute percentage of matriculants into all U.S. MD-PhD programs was performed for self-reported sex and race/ethnicity, using Association of American Medical Colleges data for AYs 2009-2018, including an interaction for MSTP funding status (yes/no) and year. Linear regression of the percentage of programs matriculating no female or no URM students between AYs 2009 and 2018 was performed, focusing on programs in the top 3 quartiles by size (i.e., those matriculating 4 or more students per year). RESULTS: Between AYs 2009 and 2018, the percentage of matriculants to all MD-PhD programs who were female (38.0%-46.0%, 1.05%/year, P = .002) or URM (9.8%-16.7%, 0.77%/year, P < .001) increased. The annual percentage gains of URM matriculants were greater at MSTP-funded programs compared with non-MSTP-funded programs (0.50%/year, P = .046). Moreover, among MD-PhD programs in the top 3 quartiles by size, the percentage of programs with no female matriculants decreased by 0.40% per year ( P = .02) from 4.6% in 2009 to 1.6% in 2018, and the percentage of programs with no URM matriculants decreased by 3.41% per year ( P < .001) from 49% in 2009 to 22% in 2018. CONCLUSIONS: A consistent and sustained increase in the percentage of female and URM matriculants to MD-PhD programs from AYs 2009-2018 was observed, but the annual increases in the percentages across groups were small, and the demographics of the MD-PhD workforce still do not reflect the diversity of the U.S. general population.

Neighbourhood walking tours for physicians-in-training.

Social and economic factors have a profound impact on patient health. However, education about these factors has been inconsistently incorporated into residency training. Neighbourhood walking tours may help physician-residents learn about the social determinants of health (SDoH). We assessed the impact of a neighbourhood walking tour on physician-residents' perceptions of SDoH, plans for counselling patients and knowledge of community resources. Using a community-based participatory research approach, in 2017 we implemented a neighbourhood walking tour curriculum for physician-residents in internal medicine, internal medicine/primary care, emergency medicine, paediatrics, combined internal medicine/paediatrics and obstetrics/gynaecology. In both pre-tour and post-tour, we asked participants to (1) rank the importance of individual-level and neighbourhood-level factors affecting patients' health, (2) describe strategies used to improve health behaviours and (3) describe knowledge of community resources. Eighty-one physician-residents participated in walks (pre-tour surveys (93% participation rate (n=75)), and post-tour surveys (53% participation rate (n=43)). Pre-tour, the factor ranked most frequently affecting patient health was 'access to primary care' (67%) compared with post-tour: 'income' (44%) and 'transportation' (44%). In describing ways to improve diet and exercise, among pre-tour survey respondents, 67% discussed individual-level strategies and 16% discussed neighbourhood-level, while among post-tour survey respondents, 39% of respondents discussed individual-level strategies and 37% discussed neighbourhood-level. Percentage of respondents aware of community resources changed from 5% to 76% (p<0.001). Walking tours helped physician-residents recognise the importance of SDoH and the value of community resources, and may have broadened frameworks for counselling patients on healthy lifestyles.

"I wanted to participate in my own care": Evaluation of a Patient Navigation Program.

INTRODUCTION: Patient navigation programs can help people overcome barriers to outpatient care. Patient experiences with these programs are not well understood. The goal of this study was to understand patient experiences and satisfaction with an emergency department (ED)-initiated patient navigation (ED-PN) intervention for US Medicaid-enrolled frequent ED users. METHODS: We conducted a mixed-methods evaluation of patient experiences and satisfaction with an ED-PN program for patients who visited the ED more than four times in the prior year. Participants were Medicaid-enrolled, English- or Spanish-speaking, New Haven-CT residents over the age of 18. Pre-post ED-PN intervention surveys and post-ED-PN individual interviews were conducted. We analyzed baseline and follow-up survey responses as proportions of total responses. Interviews were coded by multiple readers, and interview themes were identified by consensus. RESULTS: A total of 49 participants received ED-PN. Of those, 80% (39/49) completed the post-intervention survey. After receiving ED-PN, participants reported high satisfaction, fewer barriers to medical care, and increased confidence in their ability to coordinate and manage their medical care. Interviews were conducted until thematic saturation was reached. Four main themes emerged from 11 interviews: 1) PNs were perceived as effective navigators and advocates; 2) health-related social needs were frequent drivers of and barriers to healthcare; 3) primary care utilization depended on clinic accessibility and quality of relationships with providers and staff; and 4) the ED was viewed as providing convenient, comprehensive care for urgent needs. CONCLUSIONS: Medicaid-enrolled frequent ED users receiving ED-PN had high satisfaction and reported improved ability to manage their health conditions.