Medical Students' Progress in Detecting and Interpreting Visual and Auditory Clinical Findings.

Phenomenon: Detection of visual and auditory clinical findings is part of medical students' core clinical performance abilities that a medical education curriculum should teach, assess, and remediate. However, there is a limited understanding of how students develop these skills. While training physical exam technical skills has received significant attention and emphasis, teaching and assessing medical students' ability to detect and interpret visual and auditory clinical findings skills has been less systematic. Therefore, the purpose of this study is to investigate how medical students' visual and auditory clinical findings skills progress and develop over their four years of undergraduate medical education. This study will provide educators insights that can guide curriculum refinements that lead to improving students' abilities in this area. Approach: A computer-based progress exam was created to measure the longitudinal development of students' abilities to detect and interpret visual and auditory findings. After pilot testing, sixty test items were developed in collaboration with six clinical faculty members and two medical education researchers. The exam includes detection and description of ECG, x-ray, heart sounds, breath sounds, skin lesions, and movement findings. The exam was administered to students at the beginning of each training year since 2014. Additionally, the exam was administered to the Class of 2017 prior to their graduation. Measurement validity and reliability tests were conducted. Descriptive statistics and ANOVA were used to determine progress. Findings: More than 98% of students in four years of training completed the exam each year. The exam instrument had high reliabilities and demonstrated acceptable concurrent validity when compared with other academic performance data. Findings showed that students' visual and auditory clinical findings skills increased each training year until their fourth year. There was no performance improvement between incoming Year 4 students and graduating Year 4 students. While group means increased, class performance did not become more homogeneous across four years. Longitudinal data showed the same performance patterns as the cross-sectional data. Performance of the bottom quartile of graduating fourth-year students was not significantly higher than the performance of the top quartile of incoming first-year students who had not had formal medical training. Insights: A longitudinal study to follow learners' performance in detecting and interpreting visual and auditory clinical findings can provide meaningful insights regarding the effects of medical training programs on performance growth. The present study suggests that our medical curriculum is not effective in bringing all students to a higher level of performance in detecting and interpreting visual and auditory clinical findings. This study calls for further investigation how medical students can develop visual and auditory detection and interpretation skills in undergraduate medical education. There is a need for planned curriculum and assessment of medical students' skills in detecting and interpreting visual and auditory clinical findings.

Prospective case-control study of toe tip necrosis syndrome (TTNS) in western Canadian feedlot cattle.

A case-control study was conducted to investigate potential risk factors for toe tip necrosis syndrome (TTNS) in western Canadian feedlot cattle. Feedlot veterinarians provided hooves from 222 animals that died of either TTNS ("cases") or from all other causes ("controls"). The claws were sectioned by researchers to confirm the diagnoses; there was very good agreement between the practitioners' field diagnosis and that of the researchers (Cohen's kappa = 0.81; P < 0.001). The sole thickness of the apical white line region was thinner (P < 0.001) in the cases (3.74 mm) than the controls (4.72 mm). Claws from cases were 5.0 [95% confidence interval (CI): 1.5 to 8.6; P < 0.001] and 7.3 times (95% CI: 1.5 to 69.3; P < 0.01) more likely than those of controls to yield a heavy growth of Escherichia coli and Trueperella pyogenes, respectively. Cases were 4.4 times (95% CI: 4.4 to 22.9; P < 0.001) more likely to be acutely/transiently infected with bovine viral diarrhea virus than were controls. The findings support the hypothesis that TTNS is initiated by excessive wear along the white line, leading to separation and bacterial colonization of the 3rd phalangeal bone (P3) and associated soft tissues.

Étude prospective de cas-témoins du syndrome de la nécrose du bout des orteils dans un parc d'engraissement de l'Ouest canadien. Une étude de cas-témoins a été réalisée pour investiguer les facteurs de risques potentiels pour le syndrome de la nécrose du bout des orteils (SNBO) chez le bétail des parcs d'engraissement de l'Ouest canadien. Les vétérinaires des parcs d'engraissement ont fourni des sabots provenant de 222 animaux qui sont morts soit du SNBO («cas¼) ou d'autres causes («témoins¼). Les ongles ont été sectionnés par les chercheurs pour confirmer les diagnostics; il y avait une très bonne concordance entre le diagnostic sur le terrain des praticiens et celui des chercheurs (Kappa de Cohen = 0,81; P < 0,001). L'épaisseur de la sole dans la région de la ligne blanche atypique était plus mince (P < 0,001) dans les cas (3,74 mm) que dans les témoins (4,72 mm). Il était 5,0 fois (IC de 95 % de 1,5 à 8,6; P < 0,001) et 7,3 fois (IC de 95 % de 1,5 à 69,3; P < 0,01) plus probable que les ongles des cas donnent une croissance importante d'Escherichia coli et de Trueperella pyogenes, respectivement. Il était 4,4 fois (IC de 95 % de 4,4 à 22,9; P < 0,001) plus probable que les cas soient infectés de manière aiguë ou transitoire par le virus de la diarrhée virale des bovins comparativement aux témoins. Les résultats appuient l'hypothèse que le SNBO est amorcé par une usure excessive le long de la ligne blanche, ce qui entraîne une séparation et la colonisation bactérienne de l'os de la troisième phalange (P3) et des tissus mous connexes.(Traduit par Isabelle Vallières).

Comparison of rates of emergency department procedures and critical diagnoses in metropolitan and rural hospitals.

INTRODUCTION: Emergency medicine (EM) workforce studies show low rates of board-certified/residency-trained emergency physicians practising in rural emergency departments (EDs) in the USA. Rural ED rotations for EM residents may lead to increased numbers of residency-trained EM providers in rural areas. There is concern that residents trained in rural environments will not get sufficient procedural experience or patient acuity. The current literature contains only one single-residency study that provides procedural experience and patient acuity comparison between metropolitan and rural EDs. The purpose of this study is to utilize the Nationwide Emergency Department Sample (NEDS) to compare the rate of selected procedures and critical diagnoses at rural and metropolitan EDs in the USA. METHODS: The NEDS database contains ED visit records from 958 hospitals and approximates a 20% stratified sample of US hospital-based EDs. The procedures analyzed were chosen based upon the Emergency Medicine Residency Review Committee's guidelines for procedural competency and the critical diagnoses were selected based upon the American College of Emergency Physicians Model of the Clinical Practice of Emergency Medicine. Procedures and critical patient diagnoses were identified in the NEDS database by International Classification of Diseases (9th revision) code. The rates of eight procedures and twelve critical diagnoses are compared between two categories: The metropolitan category includes hospitals that are in counties defined as large or small metropolitan; the rural category includes hospitals that are in counties defined as micropolitan or non-metropolitan. RESULTS: When comparing 22 766 219 rural ED visits to 97 267 531 metropolitan ED visits there were significant differences between the rates of procedures and critical diagnoses. For all procedures analyzed, the rate at which they were performed in the rural setting versus the metropolitan was significantly lower. The decreased performance rate in rural EDs compared to metropolitan EDs was greatest for ED procedures such as fracture reduction, endotracheal intubation and lumbar puncture. Overall, procedures were performed twice as often in metropolitan EDs as compared to rural EDs. Critical diagnosis rates also tended to be lower for rural EDs when compared to metropolitan EDs. This difference in identification of critical diagnosis rate was greatest for acute myocardial infarction, cardiac dysrhythmia and ischemic cerebrovascular accident. CONCLUSIONS: The rates of critical diagnoses are similar, but are still lower in rural EDs as a recent single-site study has shown. The lower rates of procedures and critical diagnoses in rural EDs confirm the concern that residents receiving a substantial portion of their training in rural EDs may not get sufficient experience in certain procedures or critical diagnoses. The benefits of a rural ED rotation must be weighed against the risk of lower procedure and critical diagnosis rates. The impact of a 1-3 month rotation in a rural ED on overall procedural competency and clinical experience cannot, however, be extrapolated, and further study is required to quantify this effect.

Cross-sectional study of pharyngeal and genital chlamydia and gonorrhoea infections in emergency department patients.

OBJECTIVES: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the most commonly reported diseases in the USA, with increasing concern regarding cephalosporin-resistant GC strains and growing discussion of routine male screening and analysing extragenital sites. Hospital emergency departments (EDs) may be appropriate screening venues, and our objective was to identify the extent of genital and oropharyngeal CT/GC infection in ED patients. METHODS: From June 2012 to March 2013, ED patients aged 15-34 were asked to provide a urine sample and oropharyngeal swab for CT/GC analysis and complete a sexual history survey. RESULTS: The 301 female and 192 male participants had a mean age of 25.2 years (SD 4.9); were 65.5% white patients and 33.5% black patients and >85% reported sexual activity in the past year. Tested patient prevalence was 7.7% (any infection/any site; n=38) with no gender differences. Regarding oral infections (n=10), those so infected were more likely to report a friend with a sexually transmitted disease (OR=4.25; CI 1.12 to 16.20), anonymous sex in the past year (OR=5.77; CI 1.58 to 21.15) and belief of some chance of oral infection (OR=5.29; CI 1.31 to 21.28) than those not so infected. Furthermore, four had no corresponding genital infection, and 66.7% (CI 29.1% to 100%) of the oral GC infections were missing concordant genital infection. CONCLUSIONS: We find that male and female ED patients have similar likelihood of infection, that 26.3% (CI 12.4% to 40.2%) of those infected have an oral infection and that the majority of oral GC infections would not be identified or treated with urine-based screening. EDs may be important venues to identify those orally infected and provide male screening.

A multiplatform strategy for the discovery of conventional monoclonal antibodies that inhibit the voltage-gated potassium channel Kv1.3.

Identifying monoclonal antibodies that block human voltage-gated ion channels (VGICs) is a challenging endeavor exacerbated by difficulties in producing recombinant ion channel proteins in amounts that support drug discovery programs. We have developed a general strategy to address this challenge by combining high-level expression of recombinant VGICs in Tetrahymena thermophila with immunization of phylogenetically diverse species and unique screening tools that allow deep-mining for antibodies that could potentially bind functionally important regions of the protein. Using this approach, we targeted human Kv1.3, a voltage-gated potassium channel widely recognized as a therapeutic target for the treatment of a variety of T-cell mediated autoimmune diseases. Recombinant Kv1.3 was used to generate and recover 69 full-length anti-Kv1.3 mAbs from immunized chickens and llamas, of which 10 were able to inhibit Kv1.3 current. Select antibodies were shown to be potent (IC50<10 nM) and specific for Kv1.3 over related Kv1 family members, hERG and hNav1.5.

Selective suppression and excitation of solid-state NMR resonances based on quadrupole coupling constants.

The dependence of the (Rotor Assisted Population Transfer) RAPT enhancement on offset frequency for nuclei experiencing different quadrupolar couplings has been exploited to design two new spectral editing schemes, pi/2-RAPT and RAPT-pi-RAPT, for the selective excitation or suppression, respectively, of nuclei with large quadrupolar couplings. Both approaches are demonstrated on the 87 Rb spectrum of Rb(2)SO(4), which contains two resonances with C(q) values of 2.6 and 5.3 MHz. The conditions for optimal selectivity are discussed. Combining pi/2-RAPT with the RIACT MQ-MAS experiment it is also demonstrated how a pure absorption mode triple quantum MQ-MAS spectrum devoid of narrow resonances can be obtained.

Factors associated with burnout during emergency medicine residency.

OBJECTIVES: While the prevalence of burnout in practicing emergency physicians has been studied, little is known of the prevalence and risk factors in emergency medicine (EM) residents. The aim of this study was to assess the prevalence of burnout among EM residents and the individual-level factors associated with burnout. METHODS: Eight EM residency programs were surveyed using the Maslach Burnout Inventory (MBI). Demographic data and data on job satisfaction and tolerance of uncertainty in clinical decision-making were collected using validated instruments. RESULTS: Of 289 eligible residents, 218 completed the MBI (response rate = 75%). A total of 142 residents (65%) met the criteria for burnout. Complete data sets of the other instruments were obtained from 193 (response rate = 67%), and this group comprised our study population. Subjects having a significant other or spouse had a higher prevalence of burnout compared to single residents (60% vs. 40%, p = 0.002). Poor global job satisfaction (p < 0.0001), lack of administrative autonomy (p = 0.021), and lack of clinical autonomy (p = 0.031) correlated with burnout, as did intolerance of uncertainty (p = 0.015). CONCLUSIONS: Burnout is highly prevalent in EM residents. Interventions should be targeted at 1) improving resident autonomy in the emergency department where possible, 2) supervision and instruction on medical decision-making that may affect or teach individuals to cope with risk tolerance, and 3) social supports to reduce work-home conflicts during training.

Typed versus voice recognition for data entry in electronic health records: emergency physician time use and interruptions.

INTRODUCTION: Use of electronic health record (EHR) systems can place a considerable data entry burden upon the emergency department (ED) physician. Voice recognition data entry has been proposed as one mechanism to mitigate some of this burden; however, no reports are available specifically comparing emergency physician (EP) time use or number of interruptions between typed and voice recognition data entry-based EHRs. We designed this study to compare physician time use and interruptions between an EHR system using typed data entry versus an EHR with voice recognition. METHODS: We collected prospective observational data at 2 academic teaching hospital EDs, one using an EHR with typed data entry and the other with voice recognition capabilities. Independent raters observed EP activities during regular shifts. Tasks each physician performed were noted and logged in 30 second intervals. We compared time allocated to charting, direct patient care, and change in tasks leading to interruptions between sites. RESULTS: We logged 4,140 minutes of observation for this study. We detected no statistically significant differences in the time spent by EPs charting (29.4% typed; 27.5% voice) or the time allocated to direct patient care (30.7%; 30.8%). Significantly more interruptions per hour were seen with typed data entry versus voice recognition data entry (5.33 vs. 3.47; p=0.0165). CONCLUSION: The use of a voice recognition data entry system versus typed data entry did not appear to alter the amount of time physicians spend charting or performing direct patient care in an ED setting. However, we did observe a lower number of workflow interruptions with the voice recognition data entry EHR. Additional research is needed to further evaluate the data entry burden in the ED and examine alternative mechanisms for chart entry as EHR systems continue to evolve.

The impact of brief team communication, leadership and team behavior training on ad hoc team performance in trauma care settings.

BACKGROUND: Communication breakdowns and care coordination problems often cause preventable adverse patient care events, which can be especially acute in the trauma setting, in which ad hoc teams have little time for advanced planning. Existing teamwork curricula do not address the particular issues associated with ad hoc emergency teams providing trauma care. METHODS: Ad hoc trauma teams completed a preinstruction simulated trauma encounter and were provided with instruction on appropriate team behaviors and team communication. Teams completed a postinstruction simulated trauma encounter immediately afterward and 3 weeks later, then completed a questionnaire. Blinded raters rated videotapes of the simulations. RESULTS: Participants expressed high levels of satisfaction and intent to change practice after the intervention. Participants changed teamwork and communication behavior on the posttest, and changes were sustained after a 3-week interval, though there was some loss of retention. CONCLUSIONS: Brief training exercises can change teamwork and communication behaviors on ad hoc trauma teams.

Impact of an anesthesiology rotation on subsequent endotracheal intubation success.

BACKGROUND: Endotracheal intubation (ETI) is an essential skill that emergency medicine residents learn throughout their training. OBJECTIVE: To evaluate the effect of implementing a postgraduate year (PGY)-1 anesthesiology rotation on ETI success in the emergency department during PGY-2. METHODS: Residents in the study group completed a 4-week PGY-1 anesthesiology rotation. During the first 6 months of PGY-2, we compared ETI performance of the study group with a control group who did not experience a PGY-1 anesthesiology rotation. Data recorded included date, level of training, first- and second-attempt success, rescue devices used, major adverse events, and intubation scenario. A Pearson χ(2) test was used to compare first-attempt success, overall success (≤2 attempts), and adverse events rates between the 2 groups. RESULTS: Overall success rate for the study groups was 95.7% (111 of 116), compared with 94.5% (137 of 145) for the controls (P  =  66). First-attempt success for the study group was 78.4% (91 of 116), compared with 83.4% (121 of 145) for the control group; this was not statistically significant (P  = .30). Observed major and minor adverse events were similar: 19.0% for the study group (22 of 116) versus 24.8% (36 of 145) for the control group (P  = .26). CONCLUSIONS: The addition of an anesthesiology rotation to the PGY-1 curriculum did not have a significant effect on ETI success or the rate of adverse events during the first 6 months of PGY-2. First-attempt overall success and adverse events of our PGY-2 study group were consistent with previously published studies.

Rural clinical experiences for emergency medicine residents: a curriculum template.

Rural emergency departments (EDs) in the United States are less likely to be staffed with emergency medicine (EM) residency-trained and American Board of Emergency Medicine (ABEM)-certified physicians than urban EDs. Rural EM clinical experiences during residency training have been suggested as a strategy to encourage future rural practice, but past Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Emergency Medicine program requirements and a lack of familiarity with rural rotations in the EM graduate medical education (GME) community have limited their availability. To provide a template for the development and implementation of a rural EM clinical experience, Kern's six-step approach was followed.

A computational investigation of 17O quadrupolar coupling parameters and structure in alpha-quartz phase GeO2.

Ab initio band-structure calculations based on density functional theory have been completed for alpha-quartz phase GeO2 to obtain electric-field gradients (efg) for oxygen atoms, including those for GeO2 at elevated pressure and temperature. To interpret the resulting efg values and examine correlations between structure and 17O quadrupolar coupling parameters, additional ab initio self-consistent Hartree-Fock molecular orbital calculations were completed. The quadrupolar coupling constant was found to have a strong dependence on Ge-O distance and angleGe-O-Ge, with the quadrupolar asymmetry parameter being primarily dependent on angleGe-O-Ge. Analytical expressions describing these dependencies consistent with earlier investigations of analogous silicate compounds are also reported.

A combined 17O RAPT and MQ-MAS NMR study of L-leucine.

We report the application of rotor-assisted population transfer (RAPT) to measure the quadrupolar coupling constant (C(q)) for spin 5/2 nuclei. Results from numerical simulations are presented on the magnitude of enhancement factor as a function of frequency offsets, i.e. the RAPT profile. Experimental O17 RAPT profile is traced for the amino acid L-leucine. In addition, results from MQ-MAS experiments are incorporated to determine the quadrupolar asymmetry parameter (eta(q)). Unlike previous reports, the O17 NMR parameters for an amino acid, L-leucine, is reported at a relatively low field of 9.4 T.

Calculation of bridging oxygen 17O quadrupolar coupling parameters in alkali silicates: a combined ab initio investigation.

Ab initio band-structure calculations based on the density functional theory have been performed for several crystalline Li, Na, and K-silicates to obtain electric-field gradients (efg) for oxygen atoms. The efg for bridging oxygen environments in these compounds were also investigated by performing ab initio self-consistent field Hartree-Fock molecular orbital calculations on silicate clusters, and there is good agreement between these two approaches. By performing additional ab initio quantum chemistry calculations on model silicate clusters the factors influencing the 17O quadrupole coupling parameters for bridging oxygen environments in alkali silicates have been examined. The quadrupolar asymmetry parameter was found to be dependent on the Si-O-Si angle and the nature of the modifier cation, in agreement with previous studies. In contrast, the quadrupolar coupling constant was found to have a strong dependence on Si-O distance, as well as Si-O-Si angle and the nature of the modifier cation. Analytical expressions describing these dependencies are proposed, which should assist in describing the local environments of bridging oxygen in crystalline and amorphous materials.

A simple technique for determining nuclear quadrupole coupling constants with RAPT solid-state NMR spectroscopy.

An enhanced Rotor Assisted Population Transfer (RAPT) experiment is presented and used as a simple and fast technique to measure the magnitude of the nuclear quadrupolar coupling constant of half-integer quadrupolar nuclei. The enhanced RAPT sequence consists of a train of Gaussian pulses with alternating off-resonant frequencies of +/-nuoff. Simulated and experimental results demonstrating the method are given in the case of 87Rb (spin 3/2) and 27Al (spin 5/2) nuclei. The RAPT sequence is also used to selectively suppress resonances based on their quadrupolar coupling constant.

Enhancing sensitivity of quadrupolar nuclei in solid-state NMR with multiple rotor assisted population transfers.

Rotor-assisted population transfer (RAPT) was developed as a method for enhancing MAS NMR sensitivity of quadrupolar nuclei by transferring polarization associated with satellite transitions to the central m=12-->-12 transition. After a single RAPT transfer, there still remains polarization in the satellite transitions that can be transferred to the central transition. This polarization is available without having to wait for the spin system to return to thermal equilibrium. We describe a new RAPT scheme that uses the remaining polarization of the satellites to obtain a further enhancement of the central transition by performing RAPT-enhanced experiments multiple times before waiting for re-equilibration of the spin system. For 27Al (I=5/2) in albite we obtain a multiple RAPT enhancement of 3.02, a 48% increase over single RAPT. For 93Nb (I=9/2) in NaNbO(3) we obtain a multiple RAPT enhancement of 5.76, an 89% increase over single RAPT. We also describe a data processing procedure for obtaining the maximum possible signal-to-noise ratio.