Correlation of Narrative Evaluations to Clerkship Grades Using Statistical Sentiment Analysis.

Introduction: Narrative evaluations are essential components of medical student assessment. This study evaluated how well narrative clerkship evaluation word choice correlated with an assigned letter grade. Methods: One hundred clerkship evaluations, 50 from family medicine (FM) and 50 from internal medicine (IM), with even distribution of "Honors" and "Near-Honors" among medical students that graduated in 2020 from the Oregon Health and Science University (OHSU) were examined. A textual sentiment analysis, which evaluates positive and negative word choice, was used to determine each evaluation's collective sentiment. An average sentiment score and character count were calculated for Honors and Near-Honors evaluations from both clerkship disciplines. Sentiment word totals were used to form "word clouds" that highlight the most frequent word selections. Results: While sentiment scores positively correlated with the assigned grade, there was no statistically significant difference between the average sentiment scores among Honors and Near Honors graded evaluations within the FM or IM clerkship evaluation sets. There was no significant difference in evaluation character length among the assigned grades. Among FM evaluations, "outstanding" and "excellent" were the two most common sentiment words used in both Honors and Near-Honors. Among IM evaluations, outstanding and excellent were most commonly used in Honors evaluations, while "excellent" and "good" were most common in Near-Honors. Conclusion: This study outlines a novel text analysis method for analyzing narrative evaluation association with assigned grade that other institutions can utilize. Sentiment word choices are not significantly different among Honors and Near Honors clerkship narrative evaluations. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01654-2.

Endoscopy Lifetime Systems Architecture: Scoping Out the Past to Diagnose the Future Technology.

Systems engineering captures the desires and needs of the customer to conceptualize a system from the overall goal down to the small details prior to any physical development. While many systems projects tend to be large and complicated (i.e., cloud-based infrastructure, long-term space travel shuttles, missile defense systems), systems engineering can also be applied to smaller, complex systems. Here, the system of interest is the endoscope, a standard biomedical screening device used in laparoscopic surgery, screening of upper and lower gastrointestinal tracts, and inspection of the upper airway. Often, endoscopic inspection is used to identify pre-cancerous and cancerous tissues, and hence, a requirement for endoscopic systems is the ability to provide images with high contrast between areas of normal tissue and neoplasia (early-stage abnormal tissue growth). For this manuscript, the endoscope was reviewed for all the technological advancements thus far to theorize what the next version of the system could be in order to provide improved detection capabilities. Endoscopic technology was decomposed into categories, using systems architecture and systems thinking, to visualize the improvements throughout the system's lifetime from the original to current state-of-the-art. Results from this review were used to identify trends in subsystems and components to estimate the theoretical performance maxima for different subsystems as well as areas for further development. The subsystem analysis indicated that future endoscope systems will focus on more complex imaging and higher computational requirements that will provide improved contrast in order to have higher accuracy in optical diagnoses of early, abnormal tissue growth.

Association of Emergency Department Pediatric Readiness With Mortality to 1 Year Among Injured Children Treated at Trauma Centers.

IMPORTANCE: There is substantial variability among emergency departments (EDs) in their readiness to care for acutely ill and injured children, including US trauma centers. While high ED pediatric readiness is associated with improved in-hospital survival among children treated at trauma centers, the association between high ED readiness and long-term outcomes is unknown. OBJECTIVE: To evaluate the association between ED pediatric readiness and 1-year survival among injured children presenting to 146 trauma centers. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, injured children younger than 18 years who were residents of 8 states with admission, transfer to, or injury-related death at one of 146 participating trauma centers were included. Children cared for in and outside their state of residence were included. Subgroups included those with an Injury Severity Score (ISS) of 16 or more; any Abbreviated Injury Scale (AIS) score of 3 or more; head AIS score of 3 or more; and need for early critical resources. Data were collected from January 2012 to December 2017, with follow-up to December 2018. Data were analyzed from January to July 2021. EXPOSURES: ED pediatric readiness for the initial ED, measured using the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. MAIN OUTCOMES AND MEASURES: Time to death within 365 days. RESULTS: Of 88 071 included children, 30 654 (34.8%) were female; 2114 (2.4%) were Asian, 16 730 (10.0%) were Black, and 49 496 (56.2%) were White; and the median (IQR) age was 11 (5-15) years. A total of 1974 (2.2%) died within 1 year of the initial ED visit, including 1768 (2.0%) during hospitalization and 206 (0.2%) following discharge. Subgroups included 12 752 (14.5%) with an ISS of 16 or more, 28 402 (32.2%) with any AIS score of 3 or more, 13 348 (15.2%) with a head AIS of 3 or more, and 9048 (10.3%) requiring early critical resources. Compared with EDs in the lowest wPRS quartile (32-69), children cared for in the highest wPRS quartile (95-100) had lower hazard of death to 1 year (adjusted hazard ratio [aHR], 0.70; 95% CI, 0.56-0.88). Supplemental analyses removing early deaths had similar results (aHR, 0.75; 95% CI, 0.56-0.996). Findings were consistent across subgroups and multiple sensitivity analyses. CONCLUSIONS AND RELEVANCE: Children treated in high-readiness trauma center EDs after injury had a lower risk of death that persisted to 1 year. High ED readiness is independently associated with long-term survival among injured children.

Point-Of-Care Capillary Refill Technology Improves Accuracy of Peripheral Perfusion Assessment.

Background: Peripheral perfusion assessment is used routinely at the bedside by measuring the capillary refill time (CRT). Recent clinical trials have shown evidence to its ability to recognize conditions with decreased end organ perfusion as well as guiding therapeutic interventions in sepsis. However, the current standard of physician assessment at the bedside has shown large variability. New technology can improve the precision and repeatability of CRT affecting translation of previous high impact research. Methods: This was a prospective, observational study in the intensive care unit and emergency department at a quaternary care hospital using a non-invasive finger sensor for CRT. The device CRT was compared to the gold standard of trained research personnel assessment of CRT as well as to providers clinically caring for the patient. Results: Pearson correlations coefficients were performed across 89 pairs of measurements. The Pearson correlation for the device CRT compared to research personnel CRT was 0.693. The Pearson correlation for the provider CRT compared to research personnel CRT was 0.359. Conclusions: New point-of-care technology shows great promise in the ability to improve peripheral perfusion assessment performed at the bedside in the emergency department triage and during active resuscitation. This standardized approach allows for better translation of prior research that is limited by the subjectivity of manual visual assessment of CRT.

Cutting-Edge Technology for Rapid Bedside Assessment of Capillary Refill Time for Early Diagnosis and Resuscitation of Sepsis.

Sepsis currently affects over 30 million people globally with a mortality rate of ~30%. Prompt Emergency Department diagnosis and initiation of resuscitation improves outcomes; data has found an 8% increase in mortality for every hour delay in diagnosis. Once sepsis is recognized, the current Surviving Sepsis Guidelines for adult patients mandate the initiation of antibiotics within 3 h of emergency department triage as well as 30 milliliters per kilogram of intravenous fluids. While these are important parameters to follow, many emergency departments fail to meet these goals for a variety of reasons including turnaround on blood tests such as the serum lactate that may be delayed or require expensive laboratory equipment. However, patients routinely have vital signs assessed and measured in triage within 30 min of presentation. This creates a unique opportunity for implementation point for cutting-edge technology to significantly reduce the time to diagnosis of potentially septic patients allowing for earlier initiation of treatment. In addition to the practical and clinical difficulties with early diagnosis of sepsis, recent clinical trials have shown higher morbidity and mortality when septic patients are over-resuscitated. Technology allowing more real time monitoring of a patient's physiologic responses to resuscitation may allow for more individualized care in emergency department and critical care settings. One such measure at the bedside is capillary refill. This has shown favor in the ability to differentiate subsets of patients who may or may not need resuscitation and interpreting blood values more accurately (1, 2). This is a well-recognized measure of distal perfusion that has been correlated to sepsis outcomes. This physical exam finding is performed routinely, however, there is significant variability in the measurement based on who is performing it. Therefore, technology allowing rapid, objective, non-invasive measurement of capillary refill could improve sepsis recognition compared to algorithms that require lab tests included lactate or white blood count. This manuscript will discuss the broad application of capillary refill to resuscitation care and sepsis in particular for adult patients but much can be applied to pediatrics as well. The authors will then introduce a new technology that has been developed through a problem-based innovation approach to allow clinicians rapid assessment of end-organ perfusion at the bedside or emergency department triage and be incorporated into the electronic medical record. Future applications for identifying patient decompensation in the prehospital and home environment will also be discussed. This new technology has 3 significant advantages: [1] the use of reflected light technology for capillary refill assessment to provide deeper tissue penetration with less signal-to-noise ratio than transmitted infrared light, [2] the ability to significantly improve clinical outcomes without large changes to clinical workflow or provider practice, and [3] it can be used by individuals with minimal training and even in low resource settings to increase the utility of this technology. It should be noted that this perspective focuses on the utility of capillary refill for sepsis care, but it could be considered the next standard of care vital sign for assessment of end-organ perfusion. The ultimate goal for this sensor is to integrate it into existing monitors within the healthcare system.

Executive Summary: The 2018 Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps.

Emergency care providers share a compelling interest in developing an effective patient-centered, outcomes-based research agenda that can decrease variability in pediatric outcomes. The 2018 Academic Emergency Medicine Consensus Conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps (AEMCC)" aimed to fulfill this role. This conference convened major thought leaders and stakeholders to introduce a research, scholarship, and innovation agenda for pediatric emergency care specifically to reduce health outcome gaps. Planning committee and conference participants included emergency physicians, pediatric emergency physicians, pediatricians, and researchers with expertise in research dissemination and translation, as well as comparative effectiveness, in collaboration with patients, patient and family advocates from national advocacy organizations, and trainees. Topics that were explored and deliberated through subcommittee breakout sessions led by content experts included 1) pediatric emergency medical services research, 2) pediatric emergency medicine (PEM) research network collaboration, 3) PEM education for emergency medicine providers, 4) workforce development for PEM, and 5) enhancing collaboration across emergency departments (PEM practice in non-children's hospitals). The work product of this conference is a research agenda that aims to identify areas of future research, innovation, and scholarship in PEM.

Methamphetamine-related psychiatric visits to an urban academic emergency department: an observational study.

BACKGROUND: Methamphetamine, a stimulant of abuse, is associated with a significant number of Emergency Department (ED) visits. Methamphetamine use may produce psychiatric symptoms including acute psychosis, depression, and anxiety disorders. STUDY OBJECTIVES: To characterize psychiatric emergencies either directly or indirectly attributable to methamphetamine use in an urban academic ED. METHODS: We analyzed a database of patients determined to have an ED visit that was either methamphetamine related or non-methamphetamine related. We retrospectively reviewed the records of the subset of ED visits from this database with psychiatric diagnoses. We compared the characteristics of patients with methamphetamine-related psychiatric visits (MRPVs) and non-methamphetamine-related psychiatric visits (non-MRPVs). RESULTS: We identified 130 patients with MRPVs. This represented 7.6% (130 of 1709) of all psychiatric visits. Patients with MRPV, compared to non-MRPV patients, were younger (34.4 years vs. 39.1 years, respectively, p = 0.0005), more likely to be uninsured (55% vs. 37%, respectively, p = 0.001), and less likely to have a past history of depression (10% vs. 19%, respectively, p = 0.011). Many characteristics between the two groups (MRPV vs. non-MRPV) were similar: likelihood of patient being placed on a psychiatric hold; hospital charges; previous histories of psychiatric visits; and history of anxiety, bipolar disorder, or schizophrenia. CONCLUSIONS: Methamphetamine may be related to a significant proportion (7.6%) of psychiatric ED visits. Furthermore, patients with methamphetamine-associated psychiatric visits are younger, have lower rates of depression, are more likely to be uninsured, and are less likely to have a substance abuse-related chief complaint than patients with non-methamphetamine-associated ED psychiatric visits.

The association of controlling pseudoephedrine availability on methamphetamine-related emergency department visits.

OBJECTIVES: Methamphetamine is a drug of abuse that has been manufactured locally by chemical conversion from the decongestant pseudoephedrine. In July 2006, an Oregon state law was enacted to establish pseudoephedrine as a schedule III drug and make it available by prescription only. This study sought to determine if this legislation altered the number of emergency department (ED) visits that are related to methamphetamine use. METHODS: This was a retrospective analysis of a database created during a prospective study aimed at determining the effect of methamphetamine on ED visits. That prospective study was 1 year in duration and required ED clinicians to determine whether a patient's visit was related to methamphetamine and if the patient had confirmed use of methamphetamine. The clinicians received initial and continued education and training on methamphetamine during the study period. The questions were asked at every ED visit during the study period and were electronically linked to the patient's disposition and could not be circumvented. The study period was divided into prelegislation (February 5, 2006, to June 30, 2006) and postlegislation periods (July 1, 2006, to February 5, 2007). RESULTS: Over the 1-year study period, 37,625 patients were enrolled, 1.90% (n = 714) of patients had methamphetamine-related ED visits (MREDVs), and 1.65% (n = 620) had confirmed methamphetamine use. Patients with MREDVs were more likely than patients with non-MREDVs to be white and uninsured. The number and proportion of weekly MREDVs significantly decreased from the prelegislation period to the postlegislation period (mean number of weekly visits, 18.0 vs. 11.3, p = 0.001; mean proportion of weekly visits, 2.3% vs. 1.6%, p = 0.003). The number and proportion of weekly confirmed users of methamphetamine also significantly decreased during the study period (mean number of weekly users, 14.6 vs. 10.3, p = 0.004; mean proportion of weekly users, 1.9% vs. 1.4%, p = 0.017). There were no significant differences in the diagnoses of MREDVS between the pre- and postlegislation periods. CONCLUSIONS: This study found an association between the enactment of legislation that limits pseudoephedrine availability and a decrease in MREDVs and confirmed users of methamphetamine in the study ED.

Measuring nausea in emergency department patients via the use of exploratory factor analysis.

OBJECTIVES: The objective was to evaluate the applicability of a previously studied multifactorial nausea scale in the emergency department (ED) setting via exploratory factor analysis (EFA). METHODS: Two studies evaluated the validity and factor structure of 18 nausea descriptors scored on 11-point Likert scales. Trained research volunteers administered the scale to 83 men and 123 women in the first sample and to 100 men and 230 women in the second sample. All patients were assessed at enrollment and again at 90 minutes to detect changes in symptom severity. An EFA in the first study used a maximum likelihood estimation method with a principal factor analysis. The second study narrowed the descriptors and evaluated the factor structure with a confirmatory factor analysis (CFA). RESULTS: Two factors were retained in the solution; one contained five items with descriptors of physical symptoms, and a second contained five items with psychological symptoms. CFA determined that the two five-item scales were stable and reliable measures of patient nausea experience. CONCLUSIONS: The scales measure both physical and psychological symptoms of nausea, indicating that the experience is multidimensional.

Neutropenic enterocolitis.

Neutropenic enterocolitis, also known as typhlitis or ileocecal syndrome, is a rare, but important, complication of neutropenia associated with malignancy. It occurs as a result of chemotherapeutic damage to the intestinal mucosa in the context of an absolute neutropenia and can rapidly progress to intestinal perforation, multisystem organ failure, and sepsis. Presenting signs and symptoms may include fever, abdominal pain, nausea, vomiting, and diarrhea. Rapid identification and timely, aggressive medical and/or surgical intervention are the cornerstones of survival for these patients.

Best educational practices in pediatric emergency medicine during emergency medicine residency training: guiding principles and expert recommendations.

The state of pediatric emergency medicine (PEM) education within emergency medicine (EM) residency programs is reviewed and discussed in the context of shifting practice environments and new demands for a greater focus on the availability and quality of PEM services. The rapid growth of PEM within pediatrics has altered the EM practice landscape with regard to PEM. The authors evaluate the composition, quantity, and quality of PEM training in EM residency programs, with close attention paid to the challenges facing programs. A set of best practices is presented as a framework for discussion of future PEM training that would increase the yield and relevance of knowledge and experiences within the constraints of 3- and 4-year residencies. Innovative educational modalities are discussed, as well as the role of simulation and pediatric-specific patient safety education. Finally, barriers to PEM fellowship training among EM residency graduates are discussed in light of the shortage of practitioners from this training pathway and in recognition of the ongoing importance of the EM voice in PEM.

Neutropenic enterocolitis.

Neutropenic enterocolitis, also known as typhlitis or ileocecal syndrome, is a rare but important complication of neutropenia associated with malignancy. It occurs as a result of chemotherapeutic damage to the intestinal mucosa in the context of an absolute neutropenia, and can rapidly progress to intestinal perforation, multisystem organ failure, and sepsis. Presenting signs and symptoms may include fever, abdominal pain, nausea, vomiting, and diarrhea. Rapid identification by emergency physicians and timely, aggressive medical and/or surgical intervention are the cornerstones of survival for these patients.

Methamphetamine-related emergency department utilization and cost.

OBJECTIVE: To quantify the frequency, cost, and characteristics associated with emergency department (ED) visits that are related to methamphetamine use. METHODS: This was a prospective observational study. The authors performed a training program for ED clinicians on the acute and chronic effects of methamphetamine and the signs of methamphetamine abuse. A standardized two question survey was administered to clinicians concerning the relationship between the ED visit and the patient's methamphetamine use. The survey was embedded in the patient tracking system and was required for all ED patients before disposition. Survey results were merged with administrative data on demographics, diagnosis, disposition, and charges. Univariate analyses were used to determine patient characteristics associated with methamphetamine-related ED visits. RESULTS: The authors examined 15,038 ED visits over a 20-week period from February 2006 to June 2006. There were a total of 353 methamphetamine-related visits, for an average of 17.65 visits per week (2.4% of all visits). Hospital charges for methamphetamine-related ED visits averaged $133,181 per week, for an estimated total of $6.9 M in annual charges. Methamphetamine-related ED patients were more likely to be male (odds ratio [OR] 1.6, 95% confidence interval [CI] = 1.30 to 2.01), white (OR 1.8, 95% CI = 1.38 to 2.29), and uninsured (OR 3.2, 95% CI = 2.21 to 4.69). The top four medical conditions associated with methamphetamine-related visits were mental health (18.7%), trauma (18.4%), skin infections (11.1%), and dental diagnoses (9.6%). CONCLUSIONS: Methamphetamine abuse accounts for a modest but substantial proportion of ED utilization and hospital cost. Methamphetamine-related ED visits are most commonly related to mental illness, trauma, skin, and dental-related problems.

"Crystal dex:" free-base dextromethorphan.

Dextromethorphan (DXM) is a common component of combination cold medications that has become a popular drug of abuse for young adults. Abusers of DXM have developed a simple acid-base extraction technique to "free-base," or extract, the DXM from the unwanted guaifenesin, coloring agents, sweeteners, and alcohol that are typically included in combination cold preparations. We report a case of DXM overdose after ingestion of this purified "Crystal Dex" and discuss the "Agent Lemon" and single-phase extraction techniques that are used to free-base the dextromethorphan.

Junctional ectopic tachycardia in association with blunt abdominal trauma.

Junctional ectopic tachycardia is recognized predominantly as a postoperative arrhythmia after surgery for congenital heart disease. Diagnosis and treatment distinguish it from more commonly observed mechanisms of supraventricular tachycardia. We present a case of junctional ectopic tachycardia that occurred in the setting of abdominal trauma caused by child abuse and then explore the significance of this arrhythmia in a patient with trauma.