Applicant Attitudes Toward the Association of American Medical Colleges' Standardized Video Interview.

BACKGROUND: The Standardized Video Interview (SVI) was developed by the American Association of Medical Colleges to allow applicants to include objective data about professional behaviors and interpersonal and communication skills. Although the SVI pilot was administered to individuals applying to emergency medicine (EM) residency programs during the 2018 Electronic Residency Application Service (ERAS) cycle, little data have been published evaluating the applicant's perceptions. This survey aims to assess EM residency applicant attitudes toward the SVI. METHODS: During the 2018 ERAS application season an anonymous survey was administered to interviewees at one urban Accreditation Council for Graduate Medical Education-approved EM residency. Respondents were asked questions regarding the production of their video interviews, thoughts regarding the additive value of the SVI, and individual demographic data such as ethnicity and sex. Participation was optional. RESULTS: A total of 219 of 238 candidates completed the survey representing a 92% response rate. While the majority of applicants did not feel that their ethnicity impacted their application, 58.1% of those who did self-identified as African American or Asian. A total of 8.7% of respondents felt the SVI added information about their professional behaviors and 11% felt that it added information about interpersonal and communication skills. Only 2.8% of survey respondents felt the SVI should remain a portion of the ERAS application. CONCLUSIONS: Most respondents felt that the SVI was not an accurate representation of their interpersonal and communication skills or their professionalism and that it did not add value to their applications. While most cohorts were not concerned about bias regarding sex, ethnicity, sex, or age, a small subset felt that there was a potential for the SVI to bias the party reviewing their applications. Very few applicants felt the SVI should remain a part of the ERAS application. Applicant attitudes toward the SVI are largely negative and require further investigation prior to becoming a standard part of applicants' ERAS files.

Resident Supervision and Patient Care: A Comparative Time Study in a Community-Academic Versus a Community Emergency Department.

OBJECTIVE: The objective was to compare attending emergency physician (EP) time spent on direct and indirect patient care activities in emergency departments (EDs) with and without emergency medicine (EM) residents. METHODS: We performed an observational, time-motion study on 25 EPs who worked in a community-academic ED and a nonacademic community ED. Two observations of each EP were performed at each site. Average time spent per 240-minute observation on main-category activities are illustrated in percentages. We report descriptive statistics (median and interquartile ranges) for the number of minutes EPs spent per subcategory activity, in total and per patient. We performed a Wilcoxon two-sample test to assess differences between time spent across two EDs. RESULTS: The 25 observed EPs executed 34,358 tasks in the two EDs. At the community-academic ED, EPs spent 14.2% of their time supervising EM residents. Supervision activities included data presentation, medical decision making, and treatment. The time spent on supervision was offset by a decrease in time spent by EPs on indirect patient care (specifically communication and electronic health record work) at the community academic ED compared to the nonacademic community ED. There was no statistical difference with respect to direct patient care time expenditure between the two EDs. There was a nonstatistically significant difference in attending patient load between sites. CONCLUSIONS: EPs in our study spent 14.2% of their time (8.5 minutes/hour) supervising residents. The time spent supervising residents was largely offset by time savings related to indirect patient care activities rather than compromising direct patient care.

Frequency of Operative Anesthesia Care After Traumatic Injury.

BACKGROUND: Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I-V), using data from a comprehensive, regional database-the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation. METHODS: We conducted a retrospective analysis measuring the frequency of operative anesthesia care among patients enrolled in the WSTR. Univariate comparisons were made between trauma patients who had surgery during their admission and those who did not (medical management only). In addition, clinical factors associated with surgical intervention were measured. We also measured the average times from hospital admission to surgery and compared these times across trauma centers, grouped level I, II, and III-V. RESULTS: From 2004 to 2014, there were approximately 176,000 encounters meeting WSTR inclusion criteria. Approximately 60% of these trauma encounters included exposure to operative anesthesia during the admission. Among all surgical procedures during the trauma admission, approximately 33% occurred within a level I trauma center, 23% occurred within a level II trauma center, and 44% occurred in a trauma center with a III, IV, or V designation. The predominant procedure category during a trauma admission was orthopedic. The presence of hypotension on admission (P < .01), increasing injury severity score (P < .01) and higher emergency department Glasgow Coma Score (P < .01) were all associated with surgical intervention during the trauma hospitalization, after adjustment for potential confounders. In level I trauma centers, for general surgical procedures, the median time to surgery was 2.5 hours; in level II trauma centers, the median time was 1.7 hours. CONCLUSIONS: This study highlights the frequent role anesthesiologists play in caring for patients who sustain traumatic injuries, in trauma centers levels I-V. In level II trauma centers, in-house anesthesiology coverage might have benefit for those patients requiring surgery within 1 hour, whereas the former American College of Surgeons requirement of 30-minute response time for out-of-hospital anesthesiology coverage is likely sufficient to provide satisfactory care to patients requiring surgery within 3 hours. Whether the increased cost of such in-house anesthesiology coverage at level II trauma centers is justified by its clinical benefit remains an unanswered question.

Recent advances in hyaluronic acid based therapy for osteoarthritis.

Osteoarthritis is a debilitating disease that has increased in prevalence across the world due to the aging population. Currently, physicians use a plethora of treatment strategies to try and slow down the progression of the disease, but none have been shown to ubiquitously treat and cure the disease. One of the strategies uses the high molecular weight molecule hyaluronic acid as either an injectable or oral supplement for treatment. Hyaluronic acid (HA) is a relatively new treatment that has shown varied results through several clinical trials. It can be used as a scaffold for engineering new treatments and several new preparations have just been added to the market. A comprehensive search was conducted through several search databases according our inclusion and exclusion criteria. This review included 44 prospective clinical trial investigating the feasibility and efficacy of HA injection for knee, hip, and ankle osteoarthritis. This review will take a closer look at hyaluronic acid and its properties, as well clinical effectiveness and future options.

Nanoparticle doping for high power fiber lasers at eye-safer wavelengths.

A nanoparticle (NP) doping technique was developed for fabricating erbium (Er)- and holmium (Ho)-doped silica-based optical fibers for high energy lasers. Slope efficiencies in excess of 74% were realized for Er NP doping in a single mode fiber based master oscillator power amplifier (MOPA) and 53% with multi-Watt-level output in a resonantly cladding-pumped power oscillator laser configuration based on a double-clad fiber. Cores comprising Ho doped LaF3 and Lu2O3 nanoparticles exhibited slope efficiencies as high as 85% at 2.09 µm in a laser configuration. To the best of the authors' knowledge, this is the first report of a holmium nanoparticle doped fiber laser as well as the highest efficiency and power output reported from an erbium nanoparticle doped fiber laser.

Residency Applicant Preferences of Online Systems for Scheduling Interviews.

BACKGROUND: Residency applicants often have difficulty coordinating interviews with multiple programs. An online scheduling system might improve this process. OBJECTIVE: The authors sought to determine applicant mean time to schedule interviews and satisfaction using online scheduling compared with manual scheduling. METHODS: An electronic survey was sent to US graduates applying to any of 6 emergency medicine programs in the 2014-2015 application cycle. Of the participant programs, 3 used an online system and 3 did not. Applicants were asked to report estimated time to schedule with the online system compared to their average time using other methods, and to rate their satisfaction with the scheduling process. RESULTS: Of 1720 applicants to at least 1 of the 6 programs, 856 completed the survey (49.8%). Respondents reported spending less time scheduling interviews using the online system compared to other systems (median of 5 minutes [IQR 3-10] versus 60 minutes [IQR 15-240], respectively, P < .0001). In addition, applicants preferred using the online system (93.6% versus 1.4%, P < .0001.) Applicants were also more satisfied with the ease of scheduling their interviews using the online system (91.5% versus 11.0%, P < .0001) and felt that the online system aided them in coordinating travel arrangements (74.7% versus 41.5%, P < .01.). CONCLUSIONS: An online interview scheduling system is associated with time savings for applicants as well as higher satisfaction among applicants, both in ease of scheduling and in coordinating travel arrangements. The results likely are generalizable to other medical and surgical specialties.

Overview of transparent optical ceramics for high-energy lasers at NRL.

In this review, we present our recent research progress at the Naval Research Laboratory in the development of highly transparent and rugged ceramic window materials such as MgAl2O4 spinel and ß-SiC; high-power solid-state laser gain materials based on sesquioxide such as Yb(3+):Y2O3, Yb(3+):Lu2O3, and Ho(3+):Lu2O3; and composite ceramics in the application for high-energy lasers. Various powder synthesis/purification methods and powder post-process techniques necessary to create high-purity powders are described. Ceramic fabrication processes and chemical, morphological, and optical properties of the ceramics developed at the Naval Research Laboratory (NRL) are highlighted. We also report high-efficiency lasing from a hot-pressed rare-earth sesquioxide single layer and composite ceramics made from coprecipitated powder.

Addressing barriers to emergency anaphylaxis care: from emergency medical services to emergency department to outpatient follow-up.

BACKGROUND: Anaphylaxis is a systemic life-threatening allergic reaction that presents unique challenges for emergency care practitioners. Allergists and emergency physicians have a history of collaborating to promote an evidence-based, multidisciplinary approach to improve the emergency management and follow-up of patients with or at risk of anaphylaxis. OBJECTIVES: To review recent scientific literature about anaphylaxis, discuss barriers to care, and recommend strategies to support improvement in emergency anaphylaxis care. METHODS: An expert panel of allergists and emergency physicians was convened by the American College of Allergy, Asthma and Immunology in November 2014 to discuss current knowledge about anaphylaxis, identify opportunities for emergency practitioners and allergists to partner to address barriers to care, and recommend strategies to improve medical management of anaphylaxis along the continuum of care: from emergency medical systems and emergency department practitioners for acute management through appropriate outpatient follow-up with allergists to confirm diagnosis, identify triggers, and plan long-term care. RESULTS: The panel identified key barriers to anaphylaxis care, including difficulties in making an accurate diagnosis, low rates of epinephrine administration during acute management, and inadequate follow-up. Strategies to overcome these barriers were discussed and recommendations made for future allergist/emergency physician collaborations, and key messages to be communicated to emergency practitioners were proposed. CONCLUSION: The panel recommended that allergists and emergency physicians continue to work in partnership, that allergists be proactive in outreach to emergency care practitioners, and that easy-to-access educational programs and materials be developed for use by emergency medical systems and emergency department practitioners in the training environment and in practice.

Overview of transparent optical ceramics for high-energy lasers at NRL: publisher's note.

This note amends the author list of a recent publication [Appl. Opt.54, F210 (2015)].

Use of thulium-sensitized rare earth-doped low phonon energy crystalline hosts for IR sources.

Crystalline hosts with low phonon energies enable novel energy transfer processes when doped with rare earth ions. Two applications of energy transfer for rare earth ions in thulium-sensitized low phonon energy crystals that result in infrared luminescence are discussed. One application is an endothermic, phonon-assisted cross-relaxation process in thulium-doped yttrium chloride that converts lattice phonons to infrared emission, which raises the possibility of a fundamentally new method for achieving solid-state optical cooling. The other application is an optically pumped mid-IR phosphor using thulium-praseodymium-doped potassium lead chloride that converts 805-nm diode light to broadband emission from 4,000 to 5,500 nm. These two applications in chloride crystals are discussed in terms of critical radii calculated from Forster-Dexter energy transfer theory. It is found that the critical radii for electric dipole-dipole interactions in low phonon energy chloride crystals are comparable to those in conventional oxide and fluoride crystals. It is the reduction in multi-phonon relaxation rates in chloride crystals that enable these additional energy transfer processes and infrared luminescence.

Causes and trends in traumatic brain injury for United States adolescents.

Traumatic brain injury (TBI) is a leading cause of death and disability among United States adolescents. The authors sought to determine causes and trends for TBI-related hospitalizations in the United States adolescent population (10-19 years). The authors identified common causes and trends of adolescent TBI, overall and within 2-year age categories, using hospitalization data from 2005 to 2009 in the Nationwide Inpatient Sample. The leading cause of adolescent TBI overall was motor vehicle occupant accidents (35%), which are also the leading cause in the 14-15, 16-17, and 18-19 year age groups. Falls were the cause of most TBI in the 10-11 year (23%) and 12-13 year (20%) age groups. For both unintentional and intentional mechanisms of injury, there was evidence of increasing hospitalizations with increasing age. From 2005 to 2009, the overall annual incidence of adolescent TBI hospitalizations decreased 21% from an estimated 75.5-59.3 per 100,000 (p<0.001). These rates declined for mild, moderate, and severe TBI, and decreased for 2-year age groups, except for the 18-19 year-old group. For TBI attributable to motor vehicle occupants, rates declined 27% from 27.6 to 20.2 per 100,000 (p<0.001). Motor vehicle occupant injuries account for 42% of in-hospital mortality from adolescent TBI; however, firearms are the most lethal mechanism with 46% proportional mortality among victims of firearm-related TBI. Rates of adolescent TBI-related hospitalizations have decreased overall. Motor vehicle accidents and firearms were identified as leading causes of injury and mortality for adolescent TBI, and represent potential targets for intervention.

Diversity in emergency medicine education: expanding the horizon.

An emergency medicine (EM)-based curriculum on diversity, inclusion, and cultural competency can also serve as a mechanism to introduce topics on health care disparities. Although the objectives of such curricula and the potential benefits to EM trainees are apparent, there are relatively few resources available for EM program directors to use to develop these specialized curricula. The object of this article is to 1) broadly discuss the current state of curricula of diversity, inclusion, and cultural competency in EM training programs; 2) identify tools and disseminate strategies to embed issues of disparities in health care in the creation of the curriculum; and 3) provide resources for program directors to develop their own curricula. A group of EM program directors with an interest in cultural competency distributed a preworkshop survey through the Council of Emergency Medicine Residency Directors (CORD) e-mail list to EM program directors to assess the current state of diversity and cultural competency training in EM programs. Approximately 50 members attended a workshop during the 2011 CORD Academic Assembly as part of the Best Practices track, where the results of the survey were disseminated and discussed. In addition to the objectives listed above, the presenters reviewed the literature regarding the rationale for a cultural competency curriculum and its relationship to addressing health care disparities, the relationship to unconscious physician bias, and the Tool for Assessing Cultural Competence Training (TACCT) model for curriculum development.

Promoting diversity in emergency medicine: summary recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup.

Although the U.S. population continues to become more diverse, ethnic and racial health care disparities persist. The benefits of a diverse medical workforce have been well described, but the percentage of emergency medicine (EM) residents from underrepresented groups (URGs) is small and has not significantly increased over the past 10 years. The Council of Emergency Medicine Resident Directors (CORD) requested that a panel of CORD members review the current state of ethnic and racial diversity in EM training programs. The objective of the discussion was to develop strategies to help EM residency programs examine and improve diversity in their respective institutions. Specific recommendations focus on URG applicant selection and recruitment strategies, cultural competence curriculum development, involvement of URG faculty, and the availability of institutional and national resources to improve and maintain diversity in EM training programs.

Optical cooling in Er3+:KPb2Cl5.

For the first time, optical cooling has been observed in the (4)I(13/2) excited state of erbium(III), using the low phonon energy host materal, potassium lead chloride (KPb(2)Cl(2)). Cooling was observed when samples were pumped at wavelengths longer than 1557 nm, 17 nm longer than the mean fluorescence wavelength of 1540 nm, which implies a nonradiative heat load of 1.1% for the (4)I(13/2)-->(4)I(15/2) transition. When pumped at 1568 nm, the total cooling efficiency was 0.38% of the absorbed power. These results highlight the potential of Er(3+):KPb(2)Cl(5) as a material for lasers operating in an eye safe spectral region.

Conference attendance does not correlate with emergency medicine residency in-training examination scores.

OBJECTIVES: The residency review committee for emergency medicine (EM) requires residents to have greater than 70% attendance of educational conferences during residency training, but it is unknown whether attendance improves clinical competence or scores on the American Board of Emergency Medicine (ABEM) in-training examination (ITE). This study examined the relationship between conference attendance and ITE scores. The hypothesis was that greater attendance would correlate to a higher examination score. METHODS: This was a multi-center retrospective cohort study using conference attendance data and examination results from residents in four large county EM residency training programs. Longitudinal multi-level models, adjusting for training site, U.S. Medical Licensing Examination (USMLE) Step 1 score, and sex were used to explore the relationship between conference attendance and in-training examination scores according to year of training. Each year of training was studied, as well as the overall effect of mean attendance as it related to examination score. RESULTS: Four training sites reported data on 405 residents during 2002 to 2008; 386 residents had sufficient data to analyze. In the multi-level longitudinal models, attendance at conference was not a significant predictor of in-training percentile score (coefficient = 0.005, 95% confidence interval [CI] = -0.053 to 0.063, p = 0.87). Score on the USMLE Step 1 examination was a strong predictor of ITE score (coefficient = 0.186, 95% CI = 0.155 to 0.217; p < 0.001), as was female sex (coefficient = 2.117, 95% CI = 0.987 to 3.25; p < 0.001). CONCLUSIONS: Greater conference attendance does not correlate with performance on an individual's ITE scores. Conference attendance may represent an important part of EM residency training but perhaps not of ITE performance.

The effect of growth differentiation factor-5-coated sutures on tendon repair in a rat model.

Tendon ruptures are common injuries that are often treated surgically. Growth Differentiation Factor-5 (GDF-5) has been shown to accelerate tendon healing with varying degrees of success. We used a novel technique to apply recombinant human GDF-5 (rhGDF-5) to suture and hypothesized that controlled, local delivery of rhGDF-5 can be used to enhance tendon repair. Tendons of 92 rats were transected and repaired with sutures. All researchers were blinded to the following treatment groups (24 rats in each group): 0 rhGDF (control), 24 ng/cm rhGDF, 55 ng/cm rhGDF, and 556 ng/cm rhGDF. Rats were euthanized at 3 weeks (n = 48) and at 6 weeks (n = 48). Sutures were coated with rhGDF-5 using a novel dip-coat technique. Enzyme-linked immunosorbent assay confirmed consistent and reproducible delivery of rhGDF-5. Within each group, 8 were tested biomechanically, and 4 were assessed histologically. Histologic grading at 3 weeks showed improved healing in tendons repaired with coated suture versus controls. By 6 weeks, there were no significant differences. At 3 weeks, minimal isolated cartilage formation was observed; 6-week samples showed more extensive presence, typically surrounding suture fibers. At 3 weeks, tendons repaired with rhGDF-5-coated sutures resulted in significantly higher ultimate tensile load and stiffness compared with control sutures (P < .05) At 6 weeks, there were no significant differences in the mechanical properties of repaired tendons. At 3 weeks, rhGDF-5 induced significant tendon hypertrophy that was more pronounced than at 6 weeks. In addition, tendons repaired with rhGDF-5 showed an increased rate of healing versus control repairs at 3 weeks. This study showed that a novel dip-coating technique can be used to deliver growth factors in varying concentrations to local repair sites to accelerate tendon healing.

Minced cartilage without cell culture serves as an effective intraoperative cell source for cartilage repair.

Traumatic articular cartilage injuries heal poorly and may predispose patients to the early onset of osteoarthritis. One current treatment relies on surgical delivery of autologous chondrocytes that are prepared, prior to implantation, through ex vivo cell expansion of cartilage biopsy cells. The requirement for cell expansion, however, is both complex and expensive and has proven to be a major hurdle in achieving a widespread adoption of the treatment. This study presents evidence that autologous chondrocyte implantation can be delivered without requiring ex vivo cell expansion. The proposed improvement relies on mechanical fragmentation of cartilage tissue sufficient to mobilize embedded chondrocytes via increased tissue surface area. Our outgrowth study, which was used to demonstrate chondrocyte migration and growth, indicated that fragmented cartilage tissue is a rich source for chondrocyte redistribution. The chondrocytes outgrown into 3-D scaffolds also formed cartilage-like tissue when implanted in SCID mice. Direct treatment of full-thickness chondral defects in goats using cartilage fragments on a resorbable scaffold produced hyaline-like repair tissue at 6 months. Thus, delivery of chondrocytes in the form of cartilage tissue fragments in conjunction with appropriate polymeric scaffolds provides a novel intraoperative approach for cell-based cartilage repair.

Comparison of clindamycin/benzoyl peroxide, tretinoin plus clindamycin, and the combination of clindamycin/benzoyl peroxide and tretinoin plus clindamycin in the treatment of acne vulgaris: a randomized, blinded study.

In the treatment of mild to moderate acne vulgaris, the combination of an antibiotic and benzoyl peroxide provides enhanced efficacy over the individual agents, with the potential to decrease the emergence of resistant strains of P. acnes. To evaluate treatment regimens combining the daily use of a clindamycin/benzoyl peroxide gel, a tretinoin gel, and a clindamycin gel, the current randomized, evaluator-blind study was conducted. Results demonstrate that once-daily administration of clindamycin/benzoyl peroxide gel (combination formulation) was as effective as clindamycin/benzoyl peroxide gel + tretinoin gel + clindamycin gel. Both of these regimens provided greater efficacy than tretinoin + clindamycin. Treatment with clindamycin/benzoyl peroxide demonstrated a significant benefit over other treatments at Week 2, highlighting its rapid onset of action. All regimens were safe and generally well tolerated, with less severe peeling seen in patients who received clindamycin/benzoyl peroxide. In conclusion, the regimens that included clindamycin/benzoyl peroxide were more effective than tretinoin + clindamycin in the treatment of acne vulgaris, with no clinical advantage of adding tretinoin + clindamycin to once-daily clindamycin/benzoyl peroxide treatment.

Thermo-optical parameters measured in ytterbium-doped potassium gadolinium tungstate.

Oriented absorption and fluorescence spectra, refractive indices, thermal expansion, and thermal conductivities are reported for the anisotropic laser material ytterbium-doped potassium gadolinium tungstate, Yb3+:KGd(WO4)2. Measurements of negative values for dn/dT lead to the report of several useful athermal orientations for laser propagation.