Severe Hypokalemia Causing Ventricular Tachycardia: A Case Report.

Hypokalemia and hyperosmolar hyperglycemic syndrome (HHS) are two reversible but potentially fatal disorders that are important to identify and treat urgently. A 43-year-old patient presented to the ED with altered mental status and slurred speech, difficulty communicating, left-sided facial droop, and stool incontinence according to emergency medical services. This was preceded by 1.5 weeks of nausea, vomiting, polydipsia, and weight loss. On presentation, the patient was found tachycardic and tachypneic, with uncertain neurological deficits on physical exam, hyperglycemia, and electrocardiogram (EKG) abnormalities. Lab data were consistent with hyperosmolar hyperglycemic nonketotic coma. This case provides two important clinical scenarios in which cardiac EKG abnormalities and focal neurological deficits are the product of hyperosmolality and electrolyte abnormalities. Hypokalemia with EKG abnormalities consistent with a potential ischemic disease can progress into wide complex tachycardia and ventricular fibrillation. Hyperosmolar hyperglycemia may manifest with focal neurological deficits and without the classical presentation of a coma. Careful consideration of EKG and lab values in the context of clinical presentation may provide clues to resolvable etiologies. We report a case of a patient who presented to the ED with hypokalemia and HHS, both reversible but potentially fatal disorders that are important to identify and urgently treat.

Do incoming residents vary in measures of emotional status even prior to residency training?

Objectives: To determine whether Empathy, Emotional Intelligence, and Burnout scores differ by specialty in incoming residents. Methods: This is a single-site, prospective, cross-sectional study. Three validated survey instruments, the Jefferson Scale of Physician Empathy, Maslach Burnout Inventory, and Emotional and Social Competency Inventory, were written into a survey platform as a single 125-question Qualtrics survey. Over three academic years, 2015-2017, 229 incoming residents across all specialties were emailed the survey link during orientation. Residents were grouped by incoming specialty with anonymity assured. A total of 229 responses were included, with 121 (52.8%) identifying as female. Statistical analysis was performed using the Analysis of Variance or Kruskal-Wallis test, Chi-Square or Fisher's Exact test, and Independent Samples t-test or Mann Whitney U test. A Bonferroni correction was applied for pairwise comparisons. Results: Family Medicine had a higher median Jefferson Scale of Physician Empathy score (127) compared to Emergency Medicine (115), (U=767.7, p=0.0330). Maslach Burnout Inventory depersonalization and personal accomplishment subcategory scores showed a significant difference between specialties when omnibus tests were performed, but pairwise comparisons with emergency medicine residents showed no differences. Differences were found in the Maslach Burnout Inventory categories of Depersonalization (χ2(8, N=229) =15.93, p=0.0434) and Personal Accomplishment level (χ2(8, N=229) =20.80, p=0.0077) between specialties. Conclusions: Differences in measures of well-being exist across specialties, even prior to the start of residency training. The implication for educators of residency training is that some incoming residents, regardless of specialty, already exhibit troublesome features of burnout, and resources to effectively deal with these residents should be developed and utilized.

Developing Emotional Intelligence Through a Longitudinal Leadership Curriculum in UME: Combating the Decline in Medical Student Empathy.

We report on a novel curriculum (Scholarly Excellence, Leadership Experiences, Collaborative Training [SELECT]) in an allopathic medical school designed to prepare students to be physician leaders while remaining empathetic by combating burnout. SELECT students were surveyed annually. The survey contained the Jefferson Scale of Empathy (JSE) and Maslach Burnout Inventory (MBI). In this cohort, empathy did not decrease, as measured by the JSE, and SELECT students' MBI Depersonalization burnout scores decreased after year 3. In summary, in this allopathic US medical school utilizing a novel curriculum, there was no significant decline in empathy after the third year of medical school. The SELECT program appears to mitigate the decline in empathy and increased Depersonalization burnout levels often seen at the end of the third year of medical school.

Appropriate Evaluation of Psychiatric Patients Highlighted by Creutzfeldt-Jakob Disease: A Case Report.

INTRODUCTION: Determination of medical stability for patients presenting with psychiatric complaints is common for emergency clinicians. A thorough history and physical examination is important. CASE REPORT: A 53-year-old male presented to the emergency department (ED) with depression, suicidal ideation, and decline in activities of daily living over six months. While his initial neurologic examination was non-focal, subsequent re-evaluations demonstrated significant changes, and he was ultimately diagnosed with Creutzfeldt-Jakob disease. CONCLUSION: This case demonstrates how a detailed history of the present illness could have led to a more accurate and timely medical disposition from the ED.

Sex-specific Outcomes in a Substance Use Intervention Program.

PURPOSE: We performed an emergency department (ED)-based substance use screening, motivational interview-based intervention, and treatment referral program with the goal of determining sex-specific outcomes. Specifically, in this quality improvement project, we aimed to determine whether there was a difference among sexes in the type of substances used; the frequency of positive screening results for substance use disorder; agreeing to an intervention; the type of follow-up evaluation, participation, and referral; and attempts to change substance use after intervention. METHODS: We prospectively studied a convenience sample of patients at 3 hospitals in Northeastern Pennsylvania from May 2017 through February 2018. Inclusion criteria for participation in this study were age ≥18 years; ability to answer survey questions; willingness and ability (not being too ill) to participate in intervention(s); and when screened, admitting to use of alcohol, tobacco, potentially addictive prescription drugs, or street drugs. Practitioners in the ED screened patients. For those with unhealthy substance use, a brief motivational interview was performed. Participants were each given referrals and information in accordance with the particular substance used and their assessed readiness to change. Individuals who completed the intervention were contacted by telephone for follow-up. Self-reported outcomes and the frequency of successful warm hand-off referrals were assessed. FINDINGS: Of the 2209 individuals screened, 976 (44.2%) were male. Overall, 547 patients screened positive for at least 1 of the unhealthy substances for a prevalence of 24.8% (95% confidence interval, 22.9%-26.6%). In this population, a greater proportion of men screened positive than women (30.5% vs 20.2%, P = 0.01). Although the finding was not statistically significant, men (106 [35.6%]) were more likely than women (81 [32.5%]) to agree to an ED intervention. At telephone follow-up, men were more likely to report participating in a treatment or support program than women (32.9% vs 18.2%, P = 0.035). Frequencies of warm hand-off referrals were 11 of 106 (10.4%) for men and 2 of 81 (2.5%) for women. IMPLICATIONS: Our small study found that unhealthy substance use rates were greater overall in men than women. Overall participation differences between men and women who agreed to take part in substance intervention and accepted a referral for follow-up treatment were not statistically significant. At telephone follow-up, more men reported participating in a treatment program than women. Direct referral (warm hand-off) rates to treatment programs were small in both sexes but greater in men than women.

Post-traumatic left anterior descending artery dissection.

BACKGROUND: Patients who experience trauma, particularly thoracic trauma, may be at risk for missed cardiac injury. CASE REPORT: We present a case of a 36-year-old male presenting to the Emergency Department (ED) as a trauma after a high-speed motor vehicle crash. After computed tomography (CT) scans revealed a right hemopneumothorax and multiple orthopedic injuries, the patient was admitted to the trauma neuroscience intensive care unit (TNICU), where telemetry revealed ST elevations. An electrocardiogram (EKG) was performed and he was noted to have an acute anterolateral STEMI. The patient was intubated and underwent a cardiac catheterization that revealed a dissection of his left anterior descending (LAD) coronary artery and a stent was successfully placed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In cases of trauma patients who can't report the symptoms they are experiencing, or have distracting injury, there is the potential for a missed diagnosis of either significant cardiac injury and/or myocardial infarction (MI). Emergency physicians should be aware that an EKG is recommended in the ED evaluation of a trauma patient, especially those with thoracic trauma.

Brief Motivational Interviewing for Substance Use by Medical Students Is Effective in the Emergency Department.

BACKGROUND: Efficacy of medical student substance use interventions in the emergency department (ED) setting remains unstudied. OBJECTIVE: In this pilot study, we set out to determine whether medical students could perform a brief motivational interview for substance use in the ED. METHODS: At two hospitals, medical students utilized motivational interviewing skills taught by their medical school curriculum and administered a substance use intervention to ED patients who met the study definition of unhealthy substance use. RESULTS: In 6 weeks, medical students gave a brief intervention to 102 subjects. The mean age of the subjects was 46.9 (standard deviation 15.6) years. The majority, 86 (86.3%) identified as white. Fifty-four (52.9%) identified as male. Eighty of 102 (78.4%) participants completed a phone follow-up assessment. Of the 69 smokers, 11 (15.9%) reported attempting to quit or quitting completely. Of the 33 with high-risk alcohol use, 11 (33.3%) were abstaining completely from alcohol use and an additional 12 (36.4%) reported a decrease in alcohol daily consumption (measured in drinks per day). Warm hand-off success for street drugs or at-risk alcohol use was 13.6% for those who received an intervention. CONCLUSIONS: It is feasible for medical students to perform a substance use intervention in the ED setting. Medical student contributions as a part of the team response to this public health crisis provide an opportunity for further discussion and research.

Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric.

PURPOSE: The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing. METHODS: After approval by an institutional review board, a 1-year, grant-funded, single-site, prospective study was implemented at a regional medical campus that sponsors a 4-year dually approved emergency medicine residency. The residency hosts both medical school students (MSs) and physician's assistant students (PAs). Each student and senior resident working concurrently completed a previously validated ER Scale, which measured residents' teaching performance in 4 categories: Didactic, Clinical, Approachable, and Helpful. Students evaluated residents' teaching, while residents self-assessed their performance. The participants' demographic characteristics gathered included prior knowledge of or exposure to clinical teaching models. Gender was self-reported by participants. The analysis accounted for multiple observations by comparing participants' mean scores. FINDINGS: Ninety-nine subjects were enrolled; none withdrew consent. Thirty-seven residents (11 women) and 62 students (39 women) from 25 MSs and 6 PA schools were enrolled, completing 517 teaching assessments. Students evaluated residents more favorably in all ER Scale categories than did residents on self-assessments (P < 0.0001). This difference was significant in all subgroup comparisons (types of school versus postgraduate years [PGYs]). Residents' evaluations by type of student (MS vs PA) did not show a significant difference. PGY 3 residents assessed themselves higher in all categories than did PGY 4 residents, with Approachability reaching significance (P = 0.0105). Male residents self-assessed their teaching consistently higher than did female residents, significantly so on Clinical (P = 0.0300). Students' evaluations of the residents' teaching skills by residents' gender did not reveal gender differences. IMPLICATIONS: MS and PA students evaluated teaching by EM senior residents statistically significantly higher than did EM residents on self-evaluation when using the ER Scale. Students did not evaluate residents' teaching with any difference by gender, although male residents routinely self-assessed their teaching abilities more positively than did female residents. These findings suggest that, if residency programs utilize resident self-evaluation for programmatic evaluation, the gender of the resident may impact self-scoring. This cohort may inform future study of resident teaching in the emergency department, such as the design of future resident-as-teacher curricula.

LRP1 Suppresses Bone Resorption in Mice by Inhibiting the RANKL-Stimulated NF-κB and p38 Pathways During Osteoclastogenesis.

Single-nucleotide polymorphisms in the LRP1 gene coding sequence are associated with low bone mass, and cell culture studies suggest that LRP1 plays a role in osteoblast proliferation and osteoblast-mediated osteoclastogenesis. However, the in vivo function of LRP1 in bone homeostasis has not been explored. In this work, we studied the osteoclast-specific role of LRP1 in bone homeostasis using a Ctsk-Cre;Lrp1f/f mouse model on the C57BL/6J background. These mice had a dramatically decreased trabecular bone mass with markedly more osteoclasts, while the osteoblast activity was unaffected or slightly increased. The cortical bone parameters were largely unaltered. Upon RANKL treatment, Lrp1-deficient bone marrow monocytes more efficiently differentiated into osteoclasts and showed elevated p65 NFκB and p38 signaling. Consistently, Lrp1-overexpressing Raw264.7 cells were desensitized to RANKL-induced p38 and p65 activation and osteoclastogenesis. Moreover, RANKL treatment led to a sharp decrease of LRP1 protein and RNA in BMMs. Overall, our data suggest that osteoclast-expressed LRP1 is a crucial regulator of bone mass. It inhibits the NFκB and p38 pathways and lessens the efficiency of RANKL-induced osteoclastogenesis. © 2018 American Society for Bone and Mineral Research.

Use of a Clinical Pathologic Conference to Demonstrate Residents' ACGME Emergency Medicine Milestones, Aid in Faculty Development, and Increase Academic Output.

The Emergency Medicine Milestones Project, developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Emergency Medicine, includes competence targets for residents to attain and, ultimately, to exceed American Osteopathic Association and ACGME expectations for residents. The authors sought to use the clinical pathologic conference (CPC) format in their institutions' Emergency Medicine Milestones Project to provide measurable residency academic and faculty development outcomes. The CPC is an event in which a resident presents an unknown case to a discussant in advance of a didactic session to demonstrate an organized approach and decision-making rationale to a differential diagnosis. Feedback forms included the assessment of resident discussants from the perspective of level-5 Milestone achievements in particular. Developing an internal CPC competition with a dedicated core faculty coordinator who provides skill development for both resident and faculty presentation has proven successful. Such a competition can document the level-5 achievements for senior residents, be a source of faculty development, and increase peer-reviewed academic output.

Facile Synthesis of a Pentiptycene-Based Highly Microporous Organic Polymer for Gas Storage and Water Treatment.

Rigid H-shaped pentiptycene units, with an intrinsic hierarchical structure, were employed to fabricate a highly microporous organic polymer sorbent via Friedel-Crafts reaction/polymerization. The obtained microporous polymer exhibits good thermal stability, a high Brunauer-Emmett-Teller surface area of 1604 m2 g-1, outstanding CO2, H2, and CH4 storage capacities, as well as good adsorption selectivities for the separation of CO2/N2 and CO2/CH4 gas pairs. The CO2 uptake values reached as high as 5.00 mmol g-1 (1.0 bar and 273 K), which, along with high adsorption selectivity values (e.g., 47.1 for CO2/N2), make the pentiptycene-based microporous organic polymer (PMOP) a promising sorbent material for carbon capture from flue gas and natural gas purification. Moreover, the PMOP material displayed superior absorption capacities for organic solvents and dyes. For example, the maximum adsorption capacities for methylene blue and Congo red were 394 and 932 mg g-1, respectively, promoting the potential of the PMOP as an excellent sorbent for environmental remediation and water treatment.

Publisher Correction: Desumoylase SENP6 maintains osteochondroprogenitor homeostasis by suppressing the p53 pathway.

In the originally published version of this Article, the positions of the final two authors in the author list were inadvertently inverted during the production process. This error has now been corrected in both the PDF and HTML versions of the Article.

Desumoylase SENP6 maintains osteochondroprogenitor homeostasis by suppressing the p53 pathway.

The development, growth, and renewal of skeletal tissues rely on the function of osteochondroprogenitors (OCPs). Protein sumoylation/desumoylation has emerged as a pivotal mechanism for stem cell/progenitor homeostasis, and excessive sumoylation has been associated with cell senescence and tissue aging, but its role in regulating OCP function is unclear. Here we show that postnatal loss of the desumoylase SUMO1/sentrin-specific peptidase 6 (SENP6) causes premature aging. OCP-specific SENP6 knockout mice exhibit smaller skeletons, with elevated apoptosis and cell senescence in OCPs and chondrocytes. In Senp6 ‒/‒ cells, the two most significantly elevated pathways are p53 signaling and senescence-associated secreted phenotypes (SASP), and Trp53 loss partially rescues the skeletal and cellular phenotypes caused by Senp6 loss. Furthermore, SENP6 interacts with, desumoylates, and stabilizes TRIM28, suppressing p53 activity. Our data reveals a crucial role of the SENP6-p53 axis in maintaining OCP homeostasis during skeletal development.

Enhanced cortical bone expansion in Lgals3-deficient mice during aging.

Imbalances between bone formation and bone resorption, which can occur due to aging or sex hormone deprivation, result in decreased bone mass and an increased risk of fracture. Previous studies have suggested that the ß-galactoside binding lectin, galectin-3, is involved in bone remodeling. We compared bone parameters of mice having null alleles of the galectin-3 gene (Lgals3-KO) with those of their wild-type littermates. Lgals3 deficiency increased cortical bone expansion at 36 weeks (wk) and preserved or enhanced bone mass in both male and female mutant mice. In addition, female Lgals3-KO mice were protected from age-related loss of trabecular bone. Histomorphometry and ex vivo primary cell differentiation assays showed increased osteoblastogenesis with little-to-no effect on osteoclastogenesis, suggesting the increased bone mass phenotype is primarily due to increased anabolism. Our study identifies galectin-3 as a negative regulator of bone formation and suggests that disruption of galectin-3 may be useful in preventing bone loss during aging.

MRI diagnosis of herpes simplex encephalitis in an elderly man with nonspecific symptoms.

A 78-year-old male presented to the Emergency Department complaining of a 1-week onset of increasing fatigue and anorexia. The patient was previously well but had a history of depression, chronic diarrhea, and hypertension. His examination was remarkable for mild fever (100.1°F). He had no acute neurologic deficits. The patient felt better after intravenous fluids and was discharged to follow-up with the primary care provider. With no resolution of symptoms and new memory loss, the patient's primary care doctor ordered an MRI which revealed abnormal signal/patchy enhancement of the left temporal lobe indicative (pathognomonic) of herpes simplex encephalitis. This case emphasizes the importance of early consideration of herpes simplex encephalitis in the differential of patient's with these symptoms.

Standardized Direct Observation Assessment Tool: Using a Training Video.

BACKGROUND: We developed a DVD training tool to educate physicians evaluating emergency residents on accurate Standardized Direct Observation Assessment Tool (SDOT) application. OBJECTIVE: Our goal was to assess whether this training video improved attendings' and senior residents' SDOT use. METHODS: Participants voluntarily completed SDOT evaluations based on a scripted "test" video. A DVD with "positive" and "negative" scenarios of proper SDOT use was viewed. It included education on appropriate recording of 26 behaviors. The test scenario was viewed again and follow-up SDOTs submitted. Performances by attendings and residents on the pre- and post-test SDOTs were compared. RESULTS: Twenty-six attendings and 26 senior residents participated. Prior SDOT experience was noted for 8 attendings and 11 residents. For 20 anchors, participants recorded observed behaviors with statistically significant difference on one each of the pretest (no. 20; p = 0.034) and post-test (no. 14; p = 0.041) SDOTs. On global competency assessments, pretest medical knowledge (p = 0.016) differed significantly between groups. The training intervention changed one anchor (no. 5; p = 0.035) and one global assessment (systems-based practice; p = 0.031) more negatively for residents. Recording SDOTs with exact agreement occurred 48.73% for attendings pretest and 54.41% post-test; resident scores were 45.86% and 49.55%, respectively. DVD exposure slightly raised attending scores (p = 0.289) and significantly lowered resident scores (p = 0.046). CONCLUSIONS: Exposure to an independently developed SDOT training video tended to raise attending scores, though without significance, while at the same time lowered senior resident scores statistically significantly. Emergency attendings' and senior residents' SDOT scoring rarely differed with significance; about half of anchor behaviors were recorded with exact agreement. This suggests senior residents, with appropriate education, may participate in SDOT assessment.

Correlation Between United States Medical Licensing Examination and Comprehensive Osteopathic Medical Licensing Examination Scores for Applicants to a Dually Approved Emergency Medicine Residency.

BACKGROUND: It is important for emergency medicine (EM) residency programs to be able to correlate the United States (US) Medical Licensing Examination (USMLE) and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) scores of applicants. OBJECTIVE: We sought to determine the correlation between USMLE and COMLEX scores for EM residency applicants. METHODS: Retrospectively, from 2006 through 2013, USMLE and COMLEX examination scores for applicants to our 4-year, 56-member, dually approved EM residency were analyzed. Using the COMLEX score as the outcome variable and USMLE score as the predictor, multiple linear regression models, stratified by test step, were created. RESULTS: There were 556 students representing 25 discrete medical schools included. Pair 1 consisted of applicants submitting COMLEX Level-1 and USMLE Step-1 scores (n = 486). Pair 2 were those with COMLEX Level-2 and USMLE Step-2 scores (n = 356). For Pair 1, mean, standard deviation, and median scores on the COMLEX were 551, 69, and 548, respectively; for the USMLE, scores were 216, 16, and 217, respectively. Results for Pair 2 on COMLEX were 566, 80, and 562, respectively; USMLE results were 228, 18, and 229, respectively. A strong correlation was observed for Pair 1 (r = 0.78; p < 0.001). A 1-point increase in USMLE Step-1 is associated with a 3.55-point increase in the COMLEX Level-1 score (ß = 3.55; 95% confidence interval [CI] 3.30-3.80; p < 0.001). A similar strong correlation was observed for Pair 2 (r = 0.72; p < 0.001), where a 1-point increase in USMLE Step-2 is associated with a 3.29-point increase in the COMLEX Level-2 score (ß = 3.29; 95% CI 2.96-3.62; p < 0.001). CONCLUSIONS: A strong positive correlation between Steps 1 and 2 of the USMLE and COMLEX was found.

Erratum: Discovery of a highly potent glucocorticoid for asthma treatment.

[This corrects the article DOI: 10.1038/celldisc.2015.35.].