Impact of COVID-19 on Emergency Medicine Residency Programs: A Cross-Sectional Study in New York State.

INTRODUCTION: The 2019 novel coronavirus pandemic has caused significant disruptions in the clinical operations of hospitals as well as clinical education, training, and research at academic centers. New York State was among the first and largest epicenters of the pandemic, resulting in significant disruptions across its 29 emergency medicine (EM) residency programs. We conducted a cross-sectional observational study of EM residency programs in New York State to assess the impact of the pandemic on resident education and training programs. METHODS: We surveyed a cross-sectional sample of residency programs throughout New York State in June 2020, in the timeframe immediately after the state's first "wave" of the pandemic. The survey was distributed to program leadership and elicited information on pandemic-prompted curricular modifications and other educational changes. The survey covered topics related to disruptions in medical education and sought details on solutions to educational issues encountered by programs. RESULTS: Of the 29 accredited EM residency programs in New York State, leadership from 22 (76%) responded. Of these participating programs, 11 (50%) experienced high pandemic impact on clinical services, 21 (95%) canceled their own trainees' off-service rotations, 22 (100%) canceled or postponed visiting medical student rotations, 22 (100%) adopted virtual conference formats (most within the first week of the pandemic wave), and 11 (50%) stopped all prospective research (excluding COVID-19 research), while most programs continued retrospective research. CONCLUSION: This study highlights the profound educational impact of the pandemic on residency programs in one of the hardest- and earliest-hit regions in the United States. Specifically, it highlights the ubiquity of virtual conferencing, the significant impact on research, and the concerns about canceled rotations and missed training opportunities for residents, as well as prehospital and non-physician practitioner trainees. This data should be used to prompt discussion regarding the necessity of alternate educational modalities for pandemic times and the sequelae of implementing these plans.

Detection of COVID-19 using multimodal data from a wearable device: results from the first TemPredict Study.

Early detection of diseases such as COVID-19 could be a critical tool in reducing disease transmission by helping individuals recognize when they should self-isolate, seek testing, and obtain early medical intervention. Consumer wearable devices that continuously measure physiological metrics hold promise as tools for early illness detection. We gathered daily questionnaire data and physiological data using a consumer wearable (Oura Ring) from 63,153 participants, of whom 704 self-reported possible COVID-19 disease. We selected 73 of these 704 participants with reliable confirmation of COVID-19 by PCR testing and high-quality physiological data for algorithm training to identify onset of COVID-19 using machine learning classification. The algorithm identified COVID-19 an average of 2.75 days before participants sought diagnostic testing with a sensitivity of 82% and specificity of 63%. The receiving operating characteristic (ROC) area under the curve (AUC) was 0.819 (95% CI [0.809, 0.830]). Including continuous temperature yielded an AUC 4.9% higher than without this feature. For further validation, we obtained SARS CoV-2 antibody in a subset of participants and identified 10 additional participants who self-reported COVID-19 disease with antibody confirmation. The algorithm had an overall ROC AUC of 0.819 (95% CI [0.809, 0.830]), with a sensitivity of 90% and specificity of 80% in these additional participants. Finally, we observed substantial variation in accuracy based on age and biological sex. Findings highlight the importance of including temperature assessment, using continuous physiological features for alignment, and including diverse populations in algorithm development to optimize accuracy in COVID-19 detection from wearables.

Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace.

OBJECTIVES: Implicit bias contributes to both health care disparities and professional limitations, and it exists among physicians. Prior literature has described physician weight bias (WB) toward patients, but little research has investigated interphysician WB. This study describes the prevalence of interphysician implicit WB and investigates the relationships between implicit, explicit, and professional biases. The authors hypothesized that the majority of physicians possess interphysician implicit WB and that the degree of implicit bias has a direct relationship with explicit and professional WB. METHODS: In this cross-sectional study, a survey was used to measure interphysician implicit, explicit, and professional WB. It included adaptations of two previously validated measures (the Implicit Association Test and the Crandall Anti-fat Attitudes Questionnaire) and an investigator developed and tested Professional Weight Bias Scale. The survey was distributed electronically via medical society message boards, email lists, and social media groups. RESULTS: A total of 620 physicians and medical students participated. Fifty-eight percent were female, ages ranged from 22 to 83 years (mean = 44 years), and body mass index (BMI) ranged from 16 to 59 (mean = 26). Descriptive analyses revealed that 87% had some degree of implicit interphysician antifat bias, with 31% and 34% categorized as moderate and severe, respectively. Correlation and multiple regression analyses revealed that male sex, increased age, and decreased BMI were related to increased implicit bias, controlling for all other factors. Furthermore, implicit, explicit, and professional bias all had significant, direct relationships with each other. CONCLUSIONS: Our findings highlight the prevalence of interphysician implicit WB; the strong correlations between implicit, explicit, and professional WB; and the potential disparities faced by physicians with obesity. These results may be used to guide implicit bias training for a more inclusive medical workplace.

Crisis clinical pathway for COVID-19.

The pandemic of COVID-19 has been particularly severe in the New York City area, which has had one of the highest concentrations of cases in the USA. In March 2020, the EDs of New York-Presbyterian Hospital, a 10-hospital health system in the region, began to experience a rapid surge in patients with COVID-19 symptoms. Emergency physicians were faced with a disease that they knew little about that quickly overwhelmed resources. A significant amount of attention has been placed on the problem of limited supply of ventilators and intensive care beds for critically ill patients in the setting of the ongoing global pandemic. Relatively less has been given to the issue that precedes it: the demand on resources posed by patients who are not yet critically ill but are unwell enough to seek care in the ED. We describe here how at one institution, a cross-campus ED physician working group produced a care pathway to guide clinicians and ensure the fair and effective allocation of resources in the setting of the developing public health crisis. This 'crisis clinical pathway' focused on using clinical evaluation for medical decision making and maximising benefit to patients throughout the system.

Conscious Proning: An Introduction of a Proning Protocol for Nonintubated, Awake, Hypoxic Emergency Department COVID-19 Patients.

The novel coronavirus, or COVID-19, has rapidly become a global pandemic. A major cause of morbidity and mortality due to COVID-19 has been the worsening hypoxia that, if untreated, can progress to acute respiratory distress syndrome (ARDS) and respiratory failure. Past work has found that intubated patients with ARDS experience physiological benefits to the prone position, because it promotes better matching of pulmonary perfusion to ventilation, improved secretion clearance, and recruitment of dependent areas of the lungs. We created a systemwide multi-institutional (New York-Presbyterian Hospital enterprise) protocol for placing awake, nonintubated, emergency department patients with suspected or confirmed COVID-19 in the prone position. In this piece, we describe the background literature and the approach we have taken at our institution as we care for a high burden of COVID-19 cases with respiratory symptoms.

Evaluating Complications of Chronic Sinusitis.

Chronic sinusitis is a relatively common diagnosis throughout the US. In patients with an otherwise unremarkable medical history the treatment is typically supportive, requiring only clinical evaluation. We present the case of a 25-year-old male with a history of chronic sinusitis that was brought to our emergency department with new-onset seizure. Three days before he had presented to his usual care facility with two days of headache and fever and was discharged stating headache, subjective fever, and neck stiffness. After further investigation he was diagnosed with a mixed anaerobic epidural abscess. The evaluation and management of chronic sinusitis are based on the presence of symptoms concerning for complication. Prompt investigation of complicated sinusitis is essential in preventing debilitating and fatal sequelae. Our case study underscores the importance of early diagnosis and appropriate management.

Progressive Disordered Movements in an Infant Leads to Rare Diagnosis.

Desmoplastic infantile ganglioglioma (DIG) is a supratentorial superficially-located cystic neuroepithelial tumor. It is an exceedingly rare tumor with an incidence of <0.1% of central nervous tumors; approximately 60 cases have been reported in the literature. We present a case of a three-month-old infant with progressive disordered movements described as intermittent upper body stiffening with associated eye blinking, drooling, and change in level of alertness. A seizure was witnessed in the emergency department, after which the child was sent for imaging studies. Magnetic resonance imaging (MRI) revealed a large solid and cystic mass in the temporal region measuring 8.6cm × 7.9cm × 5.1cm. The infant underwent complete surgical resection, and post-surgical pathology revealed a diagnosis of DIG. The patient had an excellent post-operative course in the months following discharge. At his last well-child visit, no neurological deficits were appreciated and the infant was meeting expected milestones for his age.

Mastoiditis and meningitis complicating an aural foreign body.

Children commonly present to emergency departments with foreign bodies in the ear. In addition, physicians place wicks in the ear canal as part of the treatment of otitis externa. Usually, these foreign bodies are easily removed, but occasionally, removal must be deferred or is delayed by parents. Therefore, the dangers of retained foreign bodies are important for the emergency physician to be aware of. We report the highly unusual case of a 12-year-old girl who presented with ear pain for 3 weeks. She was found to have an ear wick in place as part of the treatment of otalgia. She was subsequently diagnosed with mastoiditis and meningitis. This is first time mastoiditis and meningitis has been reported as a complication of ear wick placement, although not the only case of an intracranial complication of an aural foreign body.

Septic bursitis: a case report and primer for the emergency clinician.

We describe the case of a 44-year-old man who presented to the Emergency Department (ED) complaining of pain and swelling over the left elbow of 1-week duration. After olecranon bursal aspiration, synovial fluid analysis yielded an increased white blood cell count (3040 cells/mm(3)) and the presence of bacteria. Culture of the fluid later grew Staphylococcus aureus. The patient was initially treated with oral antibiotics for septic bursitis and returned to the orthopedics clinic for follow-up 2 days later with interval worsening of symptoms. He was subsequently admitted for parenteral antibiotics and surgical wash-out of the affected bursa. This report briefly discusses the clinical history and appropriate diagnostic evaluation for septic olecranon bursitis, as well as the shortcomings of existing treatment guidelines.

Black tea polyphenols mimic insulin/insulin-like growth factor-1 signalling to the longevity factor FOXO1a.

In vertebrates and invertebrates, relationships between diet and health are controlled by a conserved signalling pathway responsive to insulin-like ligands. In invertebrate models for example, forkhead transcription factor family O (FOXO) transcription factors in this pathway regulate the rate of aging in response to dietary cues, and in vertebrates, obesity and age-induced deficits in the same pathway are thought to contribute to dysregulation of hepatic gluconeogenesis through genes such as phosphoenolpyruvate carboxykinase (PEPCK). Recently, we have begun to screen for dietary constituents capable of regulating this pathway in our cell culture model. Here, we identify three black tea theaflavins, theaflavin 3-O-gallate, theaflavin 3'-O-gallate, theaflavin 3,3'di-O-gallate and thearubigins as novel mimics of insulin/IGF-1 action on mammalian FOXO1a, PEPCK and moreover we provide evidence that the effects on this pathway of the green tea constituent (-)-epigallocatechin gallate depend on its ability to be converted into these larger structures. With the exception of water, tea is the most popular drink globally, but despite this, little is known about the biological availability of black tea polyphenols in vivo or the molecular target(s) mediating the effects presented here. Further investigation in these two areas might provide insight into how age-related metabolic disease may be deferred.

Epigallocatechin gallate (EGCG) mimics insulin action on the transcription factor FOXO1a and elicits cellular responses in the presence and absence of insulin.

The green tea flavonoid epigallocatechin gallate (EGCG) is one of several compounds that have been reported to have insulin-like glucose-lowering properties in mammals. EGCG is understood to act at least in part by repression of gluconeogenic genes such as phosphoenolpyruvate carboxykinase but the transcription factors that are targeted to achieve this are unknown. We show here that EGCG induces phosphorylation of insulin-sensitive residues on the transcription factor FOXO1a. Like insulin, EGCG induced FOXO1a phosphorylation is abolished by the PtdIns 3-kinase inhibitor LY294002 but not by PD98059 (an inhibitor of mitogen-activated protein kinase cascade) or by rapamycin (an inhibitor of signalling to p70 S6 kinase). EGCG differs from insulin and IGF-1 however, in that its induction of FOXO1a phosphorylation is sensitive to scavengers of reactive oxygen species (ROS). These results indicate that EGCG exerts its insulin mimetic effects at least in part by phosphorylation of the FOXOs through a mechanism that is similar but not identical to insulin and IGF-1 induced FOXO phosphorylation. Our results suggest that agents acting in the manner of EGCG may be useful antidiabetic agents.

Use of ultrasonography to identify infants for whom urinary catheterization will be unsuccessful because of insufficient urine volume: validation of the urinary bladder index.

STUDY OBJECTIVE: Frequently, attempts to obtain catheter urine samples from infants are unsuccessful because of an empty bladder, with urinary catheterization failure rates reported up to 16%. We seek to validate a sonographic urinary bladder index that will identify patients for whom catheterization will be unsuccessful. METHODS: We conducted a prospective, blinded, observational study enrolling a convenience sample of children younger than 2 years and undergoing urinary catheterization in an urban pediatric emergency department. Failure was defined as a catheterization result of less than 2 mL of urine. Urinary bladder index, a concept we created, is defined as the product of anteroposterior and transverse diameters, expressed in centimeters squared. Sensitivity and specificity were calculated with 95% confidence intervals (CIs). RESULTS: Forty-four patients were enrolled, with a median age of 8 months (range 0.5 to 24 months) and median weight of 7.8 kg (range 1.7 to 17.7 kg). Four children urinated during the procedure and were excluded. Thirty-five had urinary bladder index greater than 2.4 cm2 (range 2.5 to 15.5 cm2 ). All were successfully catheterized. Four children had urinary bladder index less than 2.4 cm2 (range 0 to 1.2 cm 2 ). No adequate samples were obtained from those children. The bladder was not visualized at all in 1 child who was successfully catheterized. Sensitivity of the urinary bladder index to identify failure to obtain 2 mL of urine was 100% (4 of 4; 95% CI 40% to 100%), specificity was 97% (35 of 36; 95% CI 85% to 100%). CONCLUSION: A urinary bladder index less than 2.4 cm2 appears to identify infants for whom urinary catheterization will be unsuccessful because of insufficient urine volume. Ultrasonographic evaluation with urinary bladder index measurement before catheterization may eliminate the incidence of failed procedures.