Motion Analysis: An Objective Assessment of Special Operations Forces and Tactical Medics Performing Point-of-Care Ultrasound.

BACKGROUND: Point-of-care ultrasound (POCUS) is commonly employed to image the heart, lungs, and abdomen. Rapid ultrasound for shock and hypotension (RUSH) exams are a critical component of POCUS employed in austere environments by Special Operations Forces (SOF) and tactical medics for triage and diagnosis. Despite its utility, training for POCUS remains largely unstandardized with respect to feedback and markers of proficiency. We hypothesized that motion analysis could objectively identify improvement in medics' performance of RUSH exams. Furthermore, we predicted that motion metrics would correlate with qualitative ratings administered by attending anesthesiologists. METHODS: A team of civilian and military attending anesthesiologists trained 24 medics in POCUS during a 5-day course. Each medic performed eight RUSH exams using an ultrasound probe equipped with an electromagnetic motion sensor to track total distance travelled (path length), movements performed (translational motions), degrees rotated (rotational sum), and time. Instructors (experts) observed and rated the exams on the following items: image finding, image fine-tuning, speed, final image accuracy, and global assessment. Motion metrics were used to provide feedback to medics throughout the course. Generalized estimating equations were used to analyze the trends of motion metrics across all trials. Correlations amongst motion metrics and expert ratings were assessed with Pearson correlation coefficients. RESULTS: Participants exhibited a negative trend in all motion metrics (p < 0.001). Pearson correlation coefficients revealed moderate inverse correlations amongst motion metrics and expert ratings. CONCLUSION: Motion analysis was able to quantify and describe the performance of medics training in POCUS and correlated with expert ratings.

Rapid Weight Gain and Weight Differential Predict Competitive Success in 2100 Professional Combat-Sport Athletes.

PURPOSE: Combat-sport athletes commonly undergo rapid weight loss prior to prebout weigh-in and subsequently rapid weight gain (RWG) prior to competition. This investigation aimed to evaluate the effect of RWG and weight differential (WD) between opponents on competitive success. METHODS: A retrospective cohort study was performed using data from professional mixed martial arts (MMA) and boxing events held between 2015 and 2019. The primary outcome was RWG (relative and absolute) between weigh-in and competition stratified by bout winners and losers. Binary logistic regression was used to explore the relationships among bout outcome, RWG, and WD between competitors on the day of their bout. RESULTS: Among 708 MMA athletes included, winners regained more relative body mass (8.7% [3.7%] vs 7.9% [3.8%], P < .01) than losers. In 1392 included male boxers, winners regained significantly more relative body mass (8.0% [3.0%] vs 6.9% [3.2%], P < .01) than losers. Each percentage body mass increase resulted in a 7% increased likelihood of victory in MMA and a 13% increase in boxing. The relationship between RWG and competitive success remained significant in regional and male international MMA athletes, as well as boxers. WD predicted victory in international mixed martial artists and boxers. WD predicted victory by knockout or technical knockout in international MMA athletes and regional boxers. CONCLUSION: This analysis of combat-sport athletes indicates that RWG and WD influence competitive success. These findings raise fair-play and safety concerns in these popular sports and may help guide risk-mitigating regulation strategies.

Assessing Skill Acquisition in Anesthesiology Interns Practicing Central Venous Catheter Placement Through Advancements in Motion Analysis.

OBJECTIVES: The study authors hypothesized that a combination of previously used (path length, translational motions, and time) and novel (rotational sum) motion metrics could be used to analyze learning curves of anesthesiology interns (postgraduate year 1) practicing central venous catheter placement in the simulation setting. They also explored the feasibility of using segmented motion recordings to inform deliberate practice. DESIGN: A prospective cohort study. SETTING: A single academic medical center. PARTICIPANTS: Anesthesiology interns (postgraduate year 1). INTERVENTIONS: Anesthesiology interns underwent a 2-day training course in which they performed 9 central venous catheter placements, while attached to motion sensors on the dorsum of their dominant hand and ultrasound probe. MEASUREMENTS AND MAIN RESULTS: Motion metrics were analyzed using generalized estimating equations for both the overall procedure and predefined segments. Five attending anesthesiologists performed 3 trials each for comparison. Overall, there was a negative trend in path length, translational motions, rotational sum, and time (p < 0.001), with the exception of translational motions of the ultrasound probe. Interns reached within 1 standard deviation of the attending anesthesiologists by trials 7-to-8 for most metrics. Segmentation identified specific components of the procedure that were either significantly improved upon or required deliberate practice. The novel metric of rotational sum exhibited a moderate-to-strong positive correlation with other metrics (p < 0.001). CONCLUSIONS: A comprehensive series of motion metrics was able to describe the learning curves of novices training to perform central venous catheter placement in the simulation setting. Furthermore, it was determined that segmentation may provide additional insight into skill acquisition and inform deliberate practice.

Rapid weight gain following weight cutting in male professional boxers.

OBJECTIVES: Weight classifications are used in boxing and other combat sports to match opponents of similar size. Professional boxers commonly engage in a potentially harmful practice known as rapid weight loss or 'weight cutting' to make weight the day prior to competition before rehydrating and refueling. This investigation describes the prevalence and magnitude of rapid weight gain in boxers following weigh-in as well as differences in practice with respect to weight class and promotion. METHODS: This analysis describes official weight data from male professional boxers collected by the California State Athletic Commission between 2015 and 2018. A total of 399 athletes were included in the study. RESULTS: Among included athletes, 389 (97.5%) athletes gained weight between official weigh-in and competition. Total absolute body mass gained was 4.4 ± 2.2 kg corresponding to a total relative body mass gain of 7.2 ± 3.5%. Boxers competing in international promotions gained significantly more body mass than regional competitors (8.0 ± 3.0% vs. 6.6 ± 3.7%; p < 0.001). In total, 82 (20.6%) athletes gained 10% body mass or more before competition. More international competitors reached this 10% threshold than regional competitors (25.3% vs. 17.4%; p = 0.03). CONCLUSIONS: These findings indicate high prevalence and magnitude of RWG in professional boxing, particularly in boxers competing in elite international promotions.

Comprehensive Ultrasound Course for Special Operations Combat and Tactical Medics.

BACKGROUND: Advances in ultrasound technology with enhanced portability and high-quality imaging has led to a surge in its use on the battlefield by nonphysician providers. However, there is a consistent need for comprehensive and standardized ultrasound training to improve ultrasound knowledge, manual skills, and workflow understanding of nonphysician providers. MATERIALS AND METHODS: Our team designed a multimodal ultrasound course to improve ultrasound knowledge, manual skills, and workflow understanding of nine Special Operations combat medics and Special Operations tactical medics. The course was based on a flipped classroom model with a total time of 43 hours, consisting of an online component followed by live lectures and hands-on workshops. The effectiveness of the course was determined using a knowledge exam, expert ratings of manual skills using a global rating scale, and an objective structured clinical skills examination (OSCE). RESULTS: The average knowledge exam score of the medics increased from pre-course (56% ± 6.8%) to post-course (80% ± 5.0%, p < .001). Based on expert ratings, their manual skills improved from baseline to day 4 of the course for image finding (p = .007), image optimization (p = .008), image acquisition speed (p = .008), final image quality (p = .008), and global assessment (p = .008). Their average score at every OSCE station was > 91%. CONCLUSION: A comprehensive multimodal training program can be used to improve military medics' ultrasound knowledge, manual skills, and workflow understanding for various applications of ultrasound. Further research is required to develop a reliable, sustainable course.

Implementation of a risk-stratified approach to prevent postoperative nausea and vomiting in an institution with high baseline rates of prophylaxis.

BACKGROUND AND AIMS: Although a risk-adjusted approach to preventing postoperative nausea and vomiting (PONV) is generally recommended, the successful implementation of such practice without mandated protocols remains elusive. To date, such a strategy has never been adapted to curb high baseline rates of prophylaxis. MATERIAL AND METHODS: We conducted an observational study on a cohort of patients undergoing elective surgery before and after the implementation of a quality improvement initiative including a risk-stratified approach to prevent PONV. The primary outcome was the number of prophylactic interventions administered. Secondary outcome included the repetition of ineffective medications and the need for rescue medication in the post-anesthesia care unit (PACU). RESULTS: A total of 636 patients were included; 325 patients during the control period and 311 after the intervention. The educational program failed to reduce the amount of prophylactic antiemetics administered (2.0 vs. 2.6, P < 0.001) and the repeat administration of ineffective medications for rescue (16% vs. 20%, P = 0.15). More patients in the intervention group required rescue medication compared to the control group (16.9% vs. 9.7%; P = 0.04). CONCLUSION: Implementation of best practices to combat PONV remains elusive. Our results indicate that difficulties in changing provider behavior also apply to institutions with high prophylactic antiemetic administration rates.

Association of Sedation, Coma, and In-Hospital Mortality in Mechanically Ventilated Patients With Coronavirus Disease 2019-Related Acute Respiratory Distress Syndrome: A Retrospective Cohort Study.

OBJECTIVES: In patients with coronavirus disease 2019-associated acute respiratory distress syndrome, sedatives and opioids are commonly administered which may lead to increased vulnerability to neurologic dysfunction. We tested the hypothesis that patients with coronavirus disease 2019-associated acute respiratory distress syndrome are at higher risk of in-hospital mortality due to prolonged coma compared with other patients with acute respiratory distress syndrome matched for disease severity. DESIGN: Propensity-matched cohort study. SETTING: Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS: All mechanically ventilated coronavirus disease 2019 patients between March and May 2020 were identified and matched with patients with acute respiratory distress syndrome of other etiology. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using clinical data obtained from a hospital registry, we matched 114 coronavirus disease 2019 patients to 228 noncoronavirus disease 2019-related acute respiratory distress syndrome patients based on baseline disease severity. Coma was identified using the Richmond Agitation Sedation Scale less than or equal to -3. Multivariable logistic regression and mediation analyses were used to assess the percentage of comatose days, sedative medications used, and the association between coronavirus disease 2019 and in-hospital mortality. In-hospital mortality (48.3% vs 31.6%, adjusted odds ratio, 2.15; 95% CI, 1.34-3.44; p = 0.002), the percentage of comatose days (66.0% ± 31.3% vs 36.0% ± 36.9%, adjusted difference, 29.35; 95% CI, 21.45-37.24; p < 0.001), and the hypnotic agent dose (51.3% vs 17.1% of maximum hypnotic agent dose given in the cohort; p < 0.001) were higher among patients with coronavirus disease 2019. Brain imaging did not show a higher frequency of structural brain lesions in patients with coronavirus disease 2019 (6.1% vs 7.0%; p = 0.76). Hypnotic agent dose was associated with coma (adjusted coefficient, 0.61; 95% CI, 0.45-0.78; p < 0.001) and mediated (p = 0.001) coma. Coma was associated with in-hospital mortality (adjusted odds ratio, 5.84; 95% CI, 3.58-9.58; p < 0.001) and mediated 59% of in-hospital mortality (p < 0.001). CONCLUSIONS: Compared with matched patients with acute respiratory distress syndrome of other etiology, patients with coronavirus disease 2019 received higher doses of hypnotics, which was associated with prolonged coma and higher mortality.

Effects of Volatile Anesthetics on Postoperative Ischemic Stroke Incidence.

Background Preclinical studies suggest that volatile anesthetics decrease infarct volume and improve the outcome of ischemic stroke. This study aims to determine their effect during noncardiac surgery on postoperative ischemic stroke incidence. Methods and Results This was a retrospective cohort study of surgical patients undergoing general anesthesia at 2 tertiary care centers in Boston, MA, between October 2005 and September 2017. Exclusion criteria comprised brain death, age <18 years, cardiac surgery, and missing covariate data. The exposure was defined as median age-adjusted minimum alveolar concentration of all intraoperative measurements of desflurane, sevoflurane, and isoflurane. The primary outcome was postoperative ischemic stroke within 30 days. Among 314 932 patients, 1957 (0.6%) experienced the primary outcome. Higher doses of volatile anesthetics had a protective effect on postoperative ischemic stroke incidence (adjusted odds ratio per 1 minimum alveolar concentration increase 0.49, 95% CI, 0.40-0.59, P<0.001). In Cox proportional hazards regression, the effect was observed for 17 postoperative days (postoperative day 1: hazard ratio (HR), 0.56; 95% CI, 0.48-0.65; versus day 17: HR, 0.85; 95% CI, 0.74-0.99). Volatile anesthetics were also associated with lower stroke severity: Every 1-unit increase in minimum alveolar concentration was associated with a 0.006-unit decrease in the National Institutes of Health Stroke Scale (95% CI, -0.01 to -0.002, P=0.002). The effects were robust throughout various sensitivity analyses including adjustment for anesthesia providers as random effect. Conclusions Among patients undergoing noncardiac surgery, volatile anesthetics showed a dose-dependent protective effect on the incidence and severity of early postoperative ischemic stroke.

Rapid Weight Gain Following Weight Cutting in Male and Female Professional Mixed Martial Artists.

Rapid weight loss or "weight cutting" is a common but potentially harmful practice used in mixed martial arts competition. Following the official weigh-in, competitors refeed and rehydrate themselves in a process known as rapid weight gain (RWG) to realize a potential competitive advantage. While data from surveys and small series have indicated the majority of mixed martial arts athletes engage in rapid weight loss, there is a lack of officially collected data from sanctioning organizations describing its prevalence. The present investigation represents a summary of the data collected between December 2015 and January 2018 by the California State Athletic Commission. In total, 512 professional mixed martial artists (455 males and 57 females) were included. Of these, 503 (98%) athletes gained body mass between weigh-in and their bouts. Total RWG between weigh-in and competition was 5.5 ± 2.5 kg, corresponding to an 8.1% ± 3.6% body mass increase. Total RWG was 5.6 ± 2.5 kg (8.1% ± 3.6%) for males and 4.5 ± 2.3 kg (8.0% ± 3.8%) for females. More than one quarter of men and one third of women gained >10% body mass between weigh-in and competition. Athletes from leading international promotions gained more absolute, but not relative, body mass than those from regional promotions. Our findings indicate RWG is nearly ubiquitous in professional , with a similar prevalence in male and female athletes. Trends based on promotion suggest a larger magnitude of RWG in presumably more experienced and/or successful mixed martial artists from leading international promotions.

Discharge Prediction for Patients Undergoing Inpatient Surgery: Development and validation of the DEPENDENSE score.

BACKGROUND: A substantial proportion of patients undergoing inpatient surgery each year is at risk for postoperative institutionalization and loss of independence. Reliable individualized preoperative prediction of adverse discharge can facilitate advanced care planning and shared decision making. METHODS: Using hospital registry data from previously home-dwelling adults undergoing inpatient surgery, we retrospectively developed and externally validated a score predicting adverse discharge. Multivariable logistic regression analysis and bootstrapping were used to develop the score. Adverse discharge was defined as in-hospital mortality or discharge to a skilled nursing facility. The model was subsequently externally validated in a cohort of patients from an independent hospital. RESULTS: In total, 106 164 patients in the development cohort and 92 962 patients in the validation cohort were included, of which 16 624 (15.7%) and 7717 (8.3%) patients experienced adverse discharge, respectively. The model was predictive of adverse discharge with an area under the receiver operating characteristic curve (AUC) of 0.87 (95% CI 0.87-0.88) in the development cohort and an AUC of 0.86 (95% CI 0.86-0.87) in the validation cohort. CONCLUSION: Using preoperatively available data, we developed and validated a prediction instrument for adverse discharge following inpatient surgery. Reliable prediction of this patient centered outcome can facilitate individualized operative planning to maximize value of care.

Ultrasound-Guided Pecto-Intercostal Fascial Block for Postoperative Pain Management in Cardiac Surgery: A Prospective, Randomized, Placebo-Controlled Trial.

OBJECTIVE: To explore the effect of pecto-intercostal fascial plane block (PIFB) on postoperative opioid requirements, pain scores, lengths of intensive care unit and hospital stays and incidence of postoperative delirium in cardiac surgical patients. DESIGN: Single- center, prospective, randomized (1:1), quadruple- blinded, placebo-controlled trial. SETTING: Single center, tertiary- care center. PARTICIPANTS: The study comprised 80 adult cardiac surgical patients (age >18 y) requiring median sternotomy. INTERVENTION: Patients were randomly assigned to receive ultrasound-guided PIFB, with either 0.25% bupivacaine or placebo, on postoperative days 0 and 1. MEASUREMENTS AND MAIN RESULTS: Of the 80 patients randomized, the mean age was 65.78 ± 8.73 in the bupivacaine group and 65.70 ± 9.86 in the placebo group (p = 0.573). Patients receiving PIFB with 0.25% bupivacaine showed a statistically significant reduction in visual analog scale scores (4.8 ± 2.7 v 5.1 ± 2.6; p < 0.001), but the 48-hour cumulative opioid requirement computed as morphine milligram equivalents was similar (40.8 ± 22.4 mg v 49.1 ± 26.9 mg; p = 0.14). There was no difference in the incidence of postoperative delirium between the groups evaluated using the 3-minute diagnostic Confusion Assessment Method (3/40 [7.5%] v 5/40 [12.5%] placebo; p = 0.45). CONCLUSION: Patients who received PIFB with bupivacaine showed a decline in cumulative opioid consumption postoperatively, but this difference between the groups was not statistically significant. Low incidence of complications and improvement in visual analog scale pain scores suggested that the PIFB can be performed safely in this population and warrants additional studies with a larger sample size.

Development of an Instrument for Preoperative Prediction of Adverse Discharge in Patients Scheduled for Cardiac Surgery.

OBJECTIVE: Inability of home discharge occurs in nearly a third of patients undergoing cardiac surgery and is associated with increased mortality. The authors aimed to evaluate the incidence and risk factors for adverse discharge disposition (ADD) after cardiac surgery and develop a prediction tool for preoperative risk assessment. DESIGN: This retrospective cohort study included adult patients undergoing cardiac surgery between 2010 and 2018. The primary outcome was ADD, defined as in-hospital mortality, discharge to a skilled nursing facility, or transfer to a long-term care hospital. The authors created a prediction tool using stepwise backward logistic regression and used 5-fold and leave-one-out cross-validation. SETTING: University hospital network. PARTICIPANTS: Adult patients living at home prior to surgery, who underwent coronary artery bypass grafting and/or valve procedures at the authors' institution. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 3,760 patients were included in the final study cohort. The observed rate of ADD was 33.3%. The prediction model showed good discrimination and accuracy, with C-statistic of 0.78 (95% confidence interval [CI] 0.76-0.79) and unmodified Brier score of 0.177 (reliability 0.001). The final model comprised 14 predictors. Patients who experienced ADD were more likely to be older, of female sex, to have had higher length of hospital stay prior to surgery, and to have undergone emergency surgery. CONCLUSIONS: The authors present an instrument for prediction of loss of the ability to live independently in patients undergoing cardiac surgery. The authors' score may be useful in identifying high-risk patients such that earlier coordination of care can be initiated in this vulnerable patient population.

Veno-venous extracorporeal membrane oxygenation allocation in the COVID-19 pandemic.

Rapid global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resultant clinical illness, coronavirus disease 2019 (COVID-19), drove the World Health Organization to declare COVID-19 a pandemic. Veno-venous Extra-Corporeal Membrane Oxygenation (VV-ECMO) is an established therapy for management of patients demonstrating the most severe forms of hypoxemic respiratory failure from COVID-19. However, features of COVID-19 pathophysiology and necessary length of treatment present distinct challenges for utilization of VV-ECMO within the current healthcare emergency. In addition, growing allocation concerns due to capacity and cost present significant challenges. Ethical and legal aspects pertinent to triage of this resource-intensive, but potentially life-saving, therapy in the setting of the COVID-19 pandemic are reviewed here. Given considerations relevant to VV-ECMO use, additional emphasis has been placed on emerging hospital resource scarcity and disproportionate representation of healthcare workers among the ill. Considerations are also discussed surrounding withdrawal of VV-ECMO and the role for early communication as well as consultation from palliative care teams and local ethics committees. In discussing how to best manage these issues in the COVID-19 pandemic at present, we identify gaps in the literature and policy important to clinicians as this crisis continues.

What Factors Predict Adverse Discharge Disposition in Patients Older Than 60 Years Undergoing Lower-extremity Surgery? The Adverse Discharge in Older Patients after Lower-extremity Surgery (ADELES) Risk Score.

BACKGROUND: Adverse discharge disposition, which is discharge to a long-term nursing home or skilled nursing facility is frequent and devastating in older patients after lower-extremity orthopaedic surgery. Predicting individual patient risk allows for preventive interventions to address modifiable risk factors and helps managing expectations. Despite a variety of risk prediction tools for perioperative morbidity in older patients, there is no tool available to predict successful recovery of a patient's ability to live independently in this highly vulnerable population. QUESTIONS/PURPOSES: In this study, we asked: (1) What factors predict adverse discharge disposition in patients older than 60 years after lower-extremity surgery? (2) Can a prediction instrument incorporating these factors be applied to another patient population with reasonable accuracy? (3) How does the instrument compare with other predictions scores that account for frailty, comorbidities, or procedural risk alone? METHODS: In this retrospective study at two competing New England university hospitals and Level 1 trauma centers with 673 and 1017 beds, respectively; 83% (19,961 of 24,095) of patients 60 years or older undergoing lower-extremity orthopaedic surgery were included. In all, 5% (1316 of 24,095) patients not living at home and 12% (2797 of 24,095) patients with missing data were excluded. All patients were living at home before surgery. The mean age was 72 ± 9 years, 60% (11,981 of 19,961) patients were female, 21% (4155 of 19,961) underwent fracture care, and 34% (6882 of 19,961) underwent elective joint replacements. Candidate predictors were tested in a multivariable logistic regression model for adverse discharge disposition in a development cohort of all 14,123 patients from the first hospital, and then included in a prediction instrument that was validated in all 5838 patients from the second hospital by calculating the area under the receiver operating characteristics curve (ROC-AUC).Thirty-eight percent (5360 of 14,262) of patients in the development cohort and 37% (2184 of 5910) of patients in the validation cohort had adverse discharge disposition. Score performance in predicting adverse discharge disposition was then compared with prediction scores considering frailty (modified Frailty Index-5 or mFI-5), comorbidities (Charlson Comorbidity Index or CCI), and procedural risks (Procedural Severity Scores for Morbidity and Mortality or PSS). RESULTS: After controlling for potential confounders like BMI, cardiac, renal and pulmonary disease, we found that the most prominent factors were age older than 90 years (10 points), hip or knee surgery (7 or 8 points), fracture management (6 points), dementia (5 points), unmarried status (3 points), federally provided insurance (2 points), and low estimated household income based on ZIP code (1 point). Higher score values indicate a higher risk of adverse discharge disposition. The score comprised 19 variables, including socioeconomic characteristics, surgical management, and comorbidities with a cutoff value of ≥ 23 points. Score performance yielded an ROC-AUC of 0.85 (95% confidence interval 0.84 to 0.85) in the development and 0.72 (95% CI 0.71 to 0.73) in the independent validation cohort, indicating excellent and good discriminative ability. Performance of the instrument in predicting adverse discharge in the validation cohort was superior to the mFI-5, CCI, and PSS (ROC-AUC 0.72 versus 0.58, 0.57, and 0.57, respectively). CONCLUSION: The Adverse Discharge in Older Patients after Lower Extremity Surgery (ADELES) score predicts adverse discharge disposition after lower-extremity surgery, reflecting loss of the ability to live independently. Its discriminative ability is better than instruments that consider frailty, comorbidities, or procedural risk alone. The ADELES score identifies modifiable risk factors, including general anesthesia and prolonged preoperative hospitalization, and should be used to streamline patient and family expectation management and improve shared decision making. Future studies need to evaluate the score in community hospitals and in institutions with different rates of adverse discharge disposition and lower income. A non-commercial calculator can be accessed at www.adeles-score.org. LEVEL OF EVIDENCE: Level III, diagnostic study.

Tool to improve qualitative assessment of left ventricular systolic function.

Interactive online learning tools have revolutionized graduate medical education and can impart echocardiographic image interpretive skills. We created self-paced, interactive online training modules using a repository of echocardiography videos of normal and various degrees of abnormal left ventricles. In this study, we tested the feasibility of this learning tool. Thirteen anesthesia interns took a pre-test and then had 3 weeks to complete the training modules on their own time before taking a post-test. The average score on the post-test (74.6% ± 11.08%) was higher than the average score on the pre-test (57.7% ± 9.27%) (P < 0.001). Scores did not differ between extreme function (severe dysfunction or hyperdynamic function) and non-extreme function (normal function or mild or moderate dysfunction) questions on both the pre-test (P = 0.278) and post-test (P = 0.093). The interns scored higher on the post-test than the pre-test on both extreme (P = 0.0062) and non-extreme (P = 0.0083) questions. After using an online educational tool that allowed learning on their own time and pace, trainees improved their ability to correctly categorize left ventricular systolic function. Left ventricular systolic function is often a key echocardiographic question that can be difficult to master. The promising performance of this educational resource may lead to more time- and cost-effective methods for improving diagnostic accuracy among learners.

Case Study: Fatal Exertional Rhabdomyolysis Possibly Related to Drastic Weight Cutting.

Rapid weight loss or "weight cutting" is a dangerous practice that is ubiquitous in modern combat sports yet underrepresented in the medical literature. We present a case of exertional rhabdomyolysis in a mixed martial artist with sickle cell trait to illustrate the hazards of weight cutting and ensuing critical illness. Sickle cell trait is known to predispose patients to exertional rhabdomyolysis, and multiple fatal cases have been reported in the setting of strenuous exercise. Dehydration and consequent electrolyte abnormalities make combat sport athletes with sickle cell trait particularly vulnerable to this entity. This case suggests a potential role for sickle cell trait screening in this population and underscores the need for safer weight-control practices and monitoring among all combat sport athletes.