Ketogenic diets, not for everyone.

BACKGROUND: The adoption of low-carbohydrate diets can lead to weight loss in many patients. However, these now widespread diets also have the potential to exacerbate hypercholesterolemia. OBJECTIVE: The objective of this study is to display the potentially harmful effects of the ketogenic diet on cholesterol levels in patients with or without underlying hyperlipidemia. METHODS: We describe 5 patients who developed marked increases in plasma cholesterol on ketogenic diets and assessed whether they had a well-described underlying genetic hyperlipidemia. RESULTS: Three out of 5 patients had extraordinary increases of blood cholesterol levels to over 500 mg/dL. The other 2 patients more than doubled their low-density lipoprotein cholesterol levels on a ketogenic diet. One patient had an APOE E2/E2 genotype. A higher burden of common genetic polymorphisms was found in 2 patients, with no major mutations found. No potential genetic cause was seen in a fourth patient, and the fifth patient had no genetic testing. Three patients, including the one who was most hypercholesterolemic, had a marked reduction in cholesterol after reverting to a more liberal diet. One refused to change his diet but had a satisfactory low-density lipoprotein cholesterol reduction on ezetimibe. CONCLUSION: These cases should serve as a caution that high-fat low-carbohydrate diets have the potential to exacerbate or cause hypercholesterolemia in patients with or without underlying genetic hyperlipidemia.

Public health education for emergency medicine residents.

Emergency medicine (EM) has an important role in public health, but the ideal approach for teaching public health to EM residents is unclear. As part of the national Regional Public Health-Medicine Education Centers-Graduate Medical Education initiative from the CDC and the American Association of Medical Colleges, three EM programs received funding to create public health curricula for EM residents. Curricula approaches varied by residency. One program used a modular, integrative approach to combine public health and EM clinical topics during usual residency didactics, one partnered with local public health organizations to provide real-world experiences for residents, and one drew on existing national as well as departmental resources to seamlessly integrate more public health-oriented educational activities within the existing residency curriculum. The modular and integrative approaches appeared to have a positive impact on resident attitudes toward public health, and a majority of EM residents at that program believed public health training is important. Reliance on pre-existing community partnerships facilitated development of public health rotations for residents. External funding for these efforts was critical to their success, given the time and financial restraints on residency programs. The optimal approach for public health education for EM residents has not been defined.

Off-service resident education in the emergency department: outline of a national standardized curriculum.

Although many residency programs mandate at least one rotation in emergency medicine (EM), to the best of our knowledge, a standardized curriculum for emergency department (ED) rotations for "off-service" residents has not been developed. As a result, the experiences of these residents in the ED tend to vary during their rotations. To design an off-service EM curriculum, we adopted Kern's six-step approach to curriculum development as a conceptual framework. The resulting program encompasses clinical experience and didactic sessions through which residents are trained in core topics and skills. This knowledge will be applicable in the clinical settings in which residents will continue to train and ultimately practice their specialty. It is flexible enough to be applicable and implementable without being limited by resource availability or faculty strengths.

Multiple encounter simulation for high-acuity multipatient environment training.

Patient safety interventions for multitasking, multipatient, error-prone work settings such as the emergency department (ED) must improve assorted clinical abilities, specific cognitive strategies, and teamwork functions of the staff to be effective. Multiple encounter simulation scenarios explore and convey this specialized mental work-set through use of multiple high-fidelity medical simulation (SIM) manikins in realistic surroundings. Multipatient scenarios reflect the work situations being targeted yet have the benefit of scripted control and instructor guidance to advance specific educational objectives. The use of two or more SIM patients promotes the exploration not only of multiple distinct clinical issues but also of interdependent processes pervasive in EDs. Cascading shortages of time, personnel, equipment, and supplies are re-created, thereby replicating process limitations at various levels, in a safe environment in which compensatory actions and adaptive behaviors can be learned. Distinguishing features of multipatient exercises include 1) broadened educational scope and expanded indications for SIM application, 2) enhanced scenario complexity, 3) controlled exposure to high workload environments, 4) expanded communication requirements, and 5) increased potential for reflective learning. Widespread and effective training in well-replicated, carefully coordinated representations of complex multipatient work environments may strengthen educational interventions for personnel working in high acuity and work-overloaded settings such as the ED. The use of concurrent patient encounter SIM exercises to elicit calculated stressors and to foster compensatory staff behaviors is an educational advance toward this objective. The authors present SIM methodology using concurrent patient encounters to replicate these environments.