Inter-rater Reliability of Sonographic Optic Nerve Sheath Diameter Measurements by Emergency Medicine Physicians.

OBJECTIVES: To compare the degree of agreement of sonographic optic nerve sheath diameter (ONSD) measurements by ultrasound fellowship-trained and resident emergency medicine (EM) physicians. METHODS: Ten ultrasound fellowship-trained EM attending physicians from multiple institutions and 51 resident EM physicians at a single residency were enrolled to measure the ONSD using a computerized ruler on five separate still-frame sonograms of adult eyes that included the retrobulbar optic nerve. Descriptive and bivariate statistics for each ultrasound image were calculated to compare median ONSD measurements among groups. Intraclass correlation coefficients (ICCs) were calculated to estimate the inter-rater reliability. RESULTS: Although the median ONSD measurement of each image did not significantly differ between resident and ultrasound fellowship-trained EM physicians, we found greater variation in agreement of ONSD measurements by resident EM physicians (ICC 0.50; 95% confidence interval 0.25-0.89) than ultrasound fellowship-trained EM physicians (ICC 0.73; 95% confidence interval 0.44-0.96). CONCLUSIONS: Although both resident and ultrasound fellowship-trained EM physicians showed good inter-rater reliability of ONSD measurements, variation in agreement among ultrasound fellowship-trained EM physicians may be as wide as 0.44, suggesting that even in skilled hands, ultrasound measurement of the ONSD may not be as dependable a screening tool for elevated intracranial pressure as previously suggested in the literature.

Validation of a Low-cost Optic Nerve Sheath Ultrasound Phantom: An Educational Tool.

OBJECTIVE: To validate an ocular phantom as a realistic educational tool utilizing in vivo and phantom optic nerve sheath (ONS) images obtained by ultrasound. METHODS: This prospective study enrolled 51 resident physicians from the Denver Health Residency in Emergency Medicine (EM) and 10 ultrasound fellowship-trained EM attending physicians. Participants performed optic nerve sheath diameter (ONSD) measurements on five in vivo and five phantom ocular ultrasound images and rated the realism of each image on a 5-point Likert scale. Chi-square analysis was performed to evaluate the subjective "realness" of in vivo and phantom images. RESULTS: Sixty-one participants performed ONSD measurements. Mean Likert scale values were 3.43 (95% confidence interval: 3.31-3.55) for in vivo images and 3.41 (95% confidence interval: 3.28-3.54) for phantom images. There was no statistical difference in subjective "realness" between in vivo and phantom ONSD ultrasound images among EM residents. Ultrasound fellowship-trained EM attending physicians aptly differentiated between in vivo (p < 0.01) and phantom (p < 0.01) images, as compared with EM residents. CONCLUSION: Our ocular phantom simulates in vivo posterior ocular anatomy. EM resident physicians found the phantom indistinguishable from in vivo images. Our ONS model provides an inexpensive and realistic educational tool to teach bedside ONSD sonography.

The Impact of the 2008 Council of Emergency Residency Directors (CORD) Panel on Emergency Medicine Resident Diversity.

BACKGROUND: In 2008, the Council of Emergency Medicine Residency Directors (CORD) developed a set of recruitment strategies designed to increase the number of under-represented minorities (URMs) in Emergency Medicine (EM) residency. OBJECTIVES: We conducted a survey of United States (US) EM residency program directors to: describe the racial and ethnic composition of residents; ascertain whether each program had instituted CORD recruitment strategies; and identify program characteristics associated with recruitment of a high proportion of URM residents. METHODS: The survey was distributed to accredited, nonmilitary US EM residency programs during 2013. Programs were dichotomized into high URM and low URM by the percentage of URM residents. High- and low-URM programs were compared with respect to size, geography, percentage of URM faculty, importance assigned to common applicant selection criteria, and CORD recruitment strategies utilized. Odds ratios and 95% confidence limits were calculated. RESULTS: Of 154 residency programs, 72% responded. The median percentage of URM residents per program was 9%. Only 46% of EM programs engaged in at least two recruitment strategies. Factors associated with higher resident diversity (high-URM) included: diversity of EM faculty (high-URM) (odds ratio [OR] 5.3; 95% confidence interval [CI] 2.1-13.0); applicant's URM status considered important (OR 4.9; 95% CI 2.1-11.9); engaging in pipeline activities (OR 4.8; 95% CI 1.4-15.7); and extracurricular activities considered important (OR 2.6; 95% CI 1.2-6.0). CONCLUSION: Less than half of EM programs have instituted two or more recruitment strategies from the 2008 CORD diversity panel. EM faculty diversity, active pipeline programs, and attention paid to applicants' URM status and extracurricular activities were associated with higher resident diversity.

Response to valganciclovir in chronic fatigue syndrome patients with human herpesvirus 6 and Epstein-Barr virus IgG antibody titers.

Valganciclovir has been reported to improve physical and cognitive symptoms in patients with chronic fatigue syndrome (CFS) with elevated human herpesvirus 6 (HHV-6) and Epstein-Barr virus (EBV) IgG antibody titers. This study investigated whether antibody titers against HHV-6 and EBV were associated with clinical response to valganciclovir in a subset of CFS patients. An uncontrolled, unblinded retrospective chart review was performed on 61 CFS patients treated with 900 mg valganciclovir daily (55 of whom took an induction dose of 1,800 mg daily for the first 3 weeks). Antibody titers were considered high if HHV-6 IgG ≥ 1:320, EBV viral capsid antigen (VCA) IgG ≥ 1:640, and EBV early antigen (EA) IgG ≥ 1:160. Patients self-rated physical and cognitive functioning as a percentage of their functioning prior to illness. Patients were categorized as responders if they experienced at least 30% improvement in physical and/or cognitive functioning. Thirty-two patients (52%) were categorized as responders. Among these, 19 patients (59%) responded physically and 26 patients (81%) responded cognitively. Baseline antibody titers showed no significant association with response. After treatment, the average change in physical and cognitive functioning levels for all patients was +19% and +23%, respectively (P < 0.0001). Longer treatment was associated with improved response (P = 0.0002). No significant difference was found between responders and non-responders among other variables analyzed. Valganciclovir treatment, independent of the baseline antibody titers, was associated with self-rated improvement in physical and cognitive functioning for CFS patients who had positive HHV-6 and/or EBV serologies. Longer valganciclovir treatment correlated with an improved response.

Increasing Resident Diversity in an Emergency Medicine Residency Program: A Pilot Intervention With Three Principal Strategies.

PROBLEM: Much work remains to be done to align the diversity of the health care workforce with the changing racial and ethnic backgrounds of patients, especially in the field of emergency medicine. APPROACH: In academic year (AY) 2012-2013, to increase the number of underrepresented minority (URM) candidates who were interviewed and matched, the Denver Health Residency in Emergency Medicine program (DHREM) initiated a focused pilot intervention with three principal strategies: (1) a scholarship-based externship program, (2) a funded second-look event, and (3) increased involvement and visibility of URM faculty in the interview and recruitment process. OUTCOMES: One year after implementation of the pilot intervention, the percentage of URMs among all applicants invited to interview at the DHREM doubled (7.1% [20/282] in AY 2011-2012, 7.0% [24/344] in AY 2012-2013, and 14.8% [58/393] in AY 2013-2014) (95% confidence interval [CI] = 5-10, 4-11, and 11-19, respectively). Of all DHREM interviewees in AY 2013-2014, 17.6% (49/279) (95% CI = 12-23) were URMs, nearly a threefold increase from AY 2012-2013 (6.2% [14/226], 95% CI = 3-10). In AY 2013-2014, 23.5% (4/17) (95% CI = 7-50) of all new DHREM residents were URMs, compared with 5.9% (1/17) in AY 2011-2012 and 5.6% (1/18) in AY 2012-2013 (95% CI = 0-29 and 0-27, respectively). NEXT STEPS: Additional studies are needed to determine whether these results are sustainable and generalizable to other residency programs in emergency medicine and other specialties.

Body mass index and prostate cancer severity: do obese men harbor more aggressive disease on prostate biopsy?

OBJECTIVE: To examine the association of obesity with the prebiopsy prostate-specific antigen (PSA), Gleason score, clinical stage, and D'Amico tumor risk in 2 independent cohorts of men with prostate cancer. MATERIALS AND METHODS: We retrospectively reviewed the medical records of men with biopsy-proven prostate cancer from California's Improving Access, Counseling and Treatment for Californians with Prostate Cancer program and from a random sample of men treated at the University of Michigan. We performed multivariate analyses to examine the relationship of body mass index (BMI) with the prebiopsy PSA level, Gleason score, clinical stage, and D'Amico tumor risk, while controlling for demographics. RESULTS: The mean age was 61.5 years, and the median prebiopsy PSA level was 6.7 ng/mL. Greater than 70% of men were at least overweight. On univariate analysis, the BMI was not associated with prebiopsy PSA levels, Gleason score, or D'Amico tumor risk. On multivariate analysis, we found no association between BMI and log-transformed PSA, Gleason score, clinical T stage, or D'Amico risk. Advancing age was associated with a greater risk of a higher prebiopsy PSA level, Gleason score, and D'Amico tumor risk. CONCLUSION: Obese men with prostate cancer were no more likely to have a higher prebiopsy PSA level, Gleason score, clinical T stage, or D'Amico risk than those of normal weight. Although we do not know whether the BMI affected the prebiopsy PSA values in those without a diagnosis of prostate cancer, our findings suggest that the BMI does not affect the interpretation of the prebiopsy PSA levels in those with cancer.

Improving telephone follow-up for patients discharged from the emergency department: results of a randomized controlled trial.

OBJECTIVES: Reliable telephone follow-up offers physicians a timely method to notify patients of unexpected laboratory and imaging results, clarify discharge instructions, evaluate health status changes, and potentially boost patient satisfaction. This study sought to determine if verifying telephone numbers, obtaining best contact times, and informing patients that they will be contacted would increase the proportion of emergency department (ED) patients contacted at 48 to 72 hours postdischarge. Secondary outcomes included estimating successful postdischarge follow-up across demographic categories. METHODS: This was a prospective, randomized controlled trial of adult patients in an inner-city, public hospital ED. Patients were excluded for critical illness, no telephone number, non-English- or non-Spanish-speaking, or anyone admitted as an inpatient. All subjects completed a demographic questionnaire. In the intervention arm, research assistants (RAs) verified the telephone number, obtained best contact times, and informed subjects that they would be called. In the control arm, telephone numbers were obtained from registration materials and were not verified, and subjects were not informed that postdischarge telephone calls were planned. RAs made four telephone attempts to contact each subject 48 to 72 hours after discharge. RESULTS: The intervention did not significantly improve postdischarge contact. Most subjects, 72.8% in the intervention group and 68.2% in the control group, were successfully contacted (difference = 4.6%, 95% confidence interval [CI] = -2.2% to 11.4%). On multivariate analysis, Hispanic ethnicity and owning a mobile phone were associated with increased odds of successful postdischarge follow-up. CONCLUSIONS: Verifying contact information, obtaining best contact times, and notifying patients of impending follow-up calls did not substantially improve postdischarge telephone contact rates.