Implementation of Formal Curriculum on Health Care Disparities in Military Family Medicine Residency.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) requires education on health care disparities (HCD), but research assessing formal curricula is limited. To improve knowledge and confidence in HCD, the family medicine residency program at Darnall Army Medical Center implemented a formal HCD curriculum. METHODS: During the 2021-2022 academic year, starting July 2021, a formal HCD curriculum was implemented for family medicine residents and faculty. Ten lectures on HCDs and implicit bias were given over the course of the year. Residents and faculty were asked to incorporate HCD into their regular continuing medical education lectures. ACGME survey data as well as a pre- and postcurriculum survey were used to assess HCD knowledge and confidence. Descriptive statistics and a paired-sample t tests were calculated to compare pre- to postcurriculum changes. RESULTS: The percentage of residents who reported that they had received HCD education increased from 72% on the 2021 ACGME survey to 100% in 2022 (N=18). We found a significant (P<.05) improvement in knowledge and confidence across 11 of 12 questions on the pre- and postcurriculum survey. CONCLUSIONS: A formal curriculum in a military family medicine residency setting was effective for improving self-reported HCD knowledge and confidence.

Respiratory Syncytial Virus Bronchiolitis: Rapid Evidence Review.

Bronchiolitis is the most common lower respiratory tract infection in young children. Respiratory syncytial virus (RSV) is the most common viral cause of bronchiolitis. RSV is spread through respiratory droplets, and the number of cases varies with season. For most patients, standard precautions (e.g., hand hygiene, surface cleaning, avoiding contact with sick individuals) are recommended. However, prophylaxis with palivizumab may be considered for infants at high risk. Initial symptoms occur after an incubation period of four to six days and include rhinorrhea, congestion, sneezing, and fever. Signs of lower respiratory tract involvement may follow and include cough, tachypnea, retractions, difficulty feeding, and accessory muscle use. Diagnosis is typically clinical; routine use of radiography or viral testing is not recommended. Treatment of RSV bronchiolitis is mainly supportive. Oxygen saturation should be maintained above 90%. Hydration and nutrition should be maintained by nasogastric or intravenous routes, if needed. Therapies such as bronchodilators, epinephrine, nebulized hypertonic saline, corticosteroids, antibiotics, and chest physiotherapy are not recommended. Although most episodes of RSV bronchiolitis are self-limited, some children have an increased risk of asthma later in life.

Acute Pancreatitis: Rapid Evidence Review.

Acute pancreatitis is the most common gastrointestinal-related reason for hospitalization in the United States. It is diagnosed based on the revised Atlanta classification, with the presence of at least two of three criteria (upper abdominal pain, serum amylase or lipase level greater than three times the upper limit of normal, or characteristic findings on imaging studies). Although computed tomography and other imaging studies can be useful to assess severity or if the diagnosis is uncertain, imaging is not required to diagnose acute pancreatitis. Based on limited studies, several scoring systems have comparable effectiveness for predicting disease severity. The presence of systemic inflammatory response syndrome on day 1 of hospital admission is highly sensitive in predicting severe disease. Treatment of acute pancreatitis involves goal-directed fluid resuscitation, analgesics, and oral feedings as tolerated on admission. If oral feedings are not tolerated, nasogastric or nasojejunal feedings are preferred over parenteral nutrition. Cholecystectomy is recommended during the initial admission for patients with mild acute biliary pancreatitis. Medical management is usually sufficient for necrotizing pancreatitis; however, if surgical intervention is needed, a minimally invasive approach is advised over direct endoscopic or open surgical debridement (necrosectomy) because of lower complication rates.

Status of US Emergency Medical Service Protocols Regarding Pre-Transfer Cooling for Exertional Heat Stroke.

OBJECTIVE:  Exertional heat stroke (EHS) is a significant cause of morbidity and mortality in athletes and active individuals. In the field, initial management of exertional heat illness is based on rapid whole-body cooling. Cold-water immersion (CWI) is considered the superior cooling modality for EHS treatment. However, there often is a disconnect between the sports medicine community and the emergency medical service (EMS) community. Well-written emergency action plans may fail if EMS protocols do not allow for CWI in initial management. This is the first study to look at the current national EMS protocols regarding prehospital management of EHS. The purpose of our study was to assess the status of heat illness protocols regarding CWI for EHS in all 50 states plus Washington, DC.  Methods: An internet search was performed to find EHS protocols. Statewide protocols were preferred. Several parameters were recorded for each protocol including whether: 1) CWI was the recommended cooling treatment for EHS and 2) CWI was explicitly permitted to be completed prior to transportation. RESULTS:  We found nine of the 51 protocols, or 17.6%, explicitly recommended CWI and 11 of the 51, or 21.6%, specifically instructed EMS personnel to complete CWI or cooling methods prior to transport. However, six protocols, or 11.8%, provided the recommendation instructing some variation of the phrase "do not delay transport to cool the patient." CONCLUSION:  Despite the medical literature endorsing CWI as the most effective treatment modality in a prehospital setting for exertional heat illness, EMS protocols largely fail to reflect this which leads to mismanagement and inadequate care of EHS patients. While CWI is not always available, all EMS protocols should include a systematic practical guideline for a heat illness patient when employing cooling treatment with an emphasis on CWI when available as the preferred treatment technique for EHS and the concept of "cool first, transport second."

Acute Hand Infections.

Acute hand infections are often caused by puncture wounds and are generally classified into superficial or deep infections. Superficial infections occur in the skin and subcutaneous tissues, whereas deep infections can involve the tendon sheaths, adjacent anatomic compartments, deep fascial planes, bursae, joint spaces, and bones. Superficial hand infections are more common than deep infections and are typically managed with elevation, warm soaks, splinting in the position of function, analgesics, and empiric antibiotics when indicated. Paronychia, which can be acute or chronic, is an infection or inflammation of the nail fold. Treatment involves warm soaks, topical antibiotics, and abscess drainage, if indicated. A felon is an infection of the distal pulp of the finger. Treatment often involves surgical drainage and empiric oral antibiotics. Herpetic whitlow is caused by herpes simplex virus and typically resolves without intervention. Deep hand infections include pyogenic flexor tenosynovitis and clenched-fist bite wounds. Pyogenic flexor tenosynovitis is a rapidly progressing bacterial infection of the flexor tendon sheaths in the hand, most commonly caused by a penetrating injury to the finger. Clenched-fist bite wounds result from direct contact of the fist on incisor teeth and are associated with polymicrobial infections. Empiric antibiotics and prompt surgical consultation are indicated to reduce long-term morbidity.