Guidance documents for colorectal and anal cancer treatment: A systematic quality and reporting assessment.

AIM: Evidence-based medicine is essential for clinical practice. Clinical practice guidelines (CPGs) and consensus statements (CSs) ought to follow a consistent methodology to underpin high-quality healthcare. We systematically analysed the quality and reporting of colorectal (CRC) and anal cancer CPGs and CSs. METHODS: Embase, MEDLINE, Scopus, Web of Science, the Cochrane Database of Systematic Reviews and online sources (59 professional society websites and eight guideline databases) were systematically searched following prospective registration (PROSPERO no. CRD42021286146) by two reviewers independently, without language restrictions. CPGs and CSs about CRC and anal cancer treatment were included from January 2018 to November 2021 and were assessed using the AGREE II tool (per cent of maximum score) and the RIGHT tool (per cent of total 35 items) for quality and reporting respectively. RESULTS: The median overall quality and reporting of the 59 guidelines analysed were 55.0% (interquartile range 47.0-62.0) and 58% (interquartile range 50.0-67.9), respectively, with a proportion scoring less than half (<50%) for quality (20/59, 33.9%) and reporting (15/59, 25.4%). Guidance reported that following AGREE II methodology scored better on average than that without (AGREE II 77.7% vs. 47.6%, P = 0.001; RIGHT 50.0% vs. 33.9%, P = 0.001). Guidelines based on systematic reviews had better quality and reporting on average than those based on consensus (AGREE II 56.5% vs. 46.6%, P = 0.001; RIGHT 36.9% vs. 35.4%, P = 0.019). CONCLUSION: The quality and reporting of colorectal and anal cancer treatment CPGs and CSs were poor. Despite AGREE II and RIGHT inherent methodological limitations, few high-quality guidelines were found. Despite wide variability in scoring different domains, they merit urgent improvement in all areas. It has also been demonstrated that CPGs and CSs should be underpinned by systematic reviews collecting the best available clinical research findings.

A Profile of Orthopedic Education in Emergency Medicine Residency Programs in the United States.

Introduction Emergency medicine (EM) residents throughout the United States are required to become skilled at performing a robust list of select orthopedic procedures, as well as learn how to diagnose and manage patients with musculoskeletal complaints. However, EM residency programs vary significantly in how they teach orthopedics and the content they cover. The purpose of this study was to profile the orthopedic education received by emergency medicine residents in United States residency programs. Methods We developed a survey based on accreditation requirements and The Model of the Clinical Practice of Emergency Medicine. The survey was designed to gather detailed information about the orthopedic education provided to EM residents. The survey was sent to EM program directors or their designees at all 263 accredited EM residency programs across the United States between October 2020 to January 2021. Results We attained a 34.6% (91 of 260) adjusted response rate with adequate representation of relevant program characteristics such as region, accreditation status, program length, size, and setting. Most (63.7%) responding programs required an orthopedics rotation during the intern year. These required orthopedic rotations were primarily four weeks in duration. The most common methods for teaching orthopedic topics included didactics (97.8%), procedures on live patients under supervision (73.3%), and assigned reading materials in textbooks or manuals (68.9%). Conclusion The orthopedic education received by EM residents in the United States is strikingly variable, with residency programs having to develop custom curricula to teach orthopedics content based on the resources available to them. Future efforts should be directed toward creating a universal curriculum that addresses accreditation and EM practice standards.

A national assessment of residency wellness initiatives in emergency medicine.

BACKGROUND: Wellness is increasingly recognized as an important component of graduate medical education. However, there are limited data regarding how wellness initiatives are enacted in practice. This study aimed to survey emergency medicine (EM) residency programs to identify current, previous, and planned wellness initiatives as well as barriers to implementation and resources utilized. METHODS: This was a cross-sectional survey study performed from November 2019 through January 2020. A literature search was performed to identify existing published wellness interventions and existing barriers, and these interventions and barriers were compiled to create a survey. The survey was piloted among five program directors and assistant program directors in person with feedback directly incorporated into the survey. The survey was sent to program leadership at all 223 Accreditation Council for Graduate Medical Education-accredited EM residency programs across the United States. RESULTS: Of the programs surveyed, 95 (42.6%) were included. The most common current wellness interventions reported were resident retreats (91%), group events (90%), formal mentorship (74%), and wellness committees (66%). Reported factors that contributed to the successful implementation of wellness interventions were faculty involvement (78%), resident involvement (78%), department chair support (51%), institutional support (44%), and financial support (36%). Lack of financial support (65%) and limited time (62%) were the most commonly reported barriers that prevented the implementation of wellness interventions. CONCLUSIONS: Resident wellness is an important aspect of residency training. Survey respondents generally perceived that wellness interventions were associated with wellness improvement. Successful programs have financial, institutional, and chair support.

Aortic Bifurcation Saddle Thrombus.

Acute aortic pathology demands a high index of suspicion and frequent reevaluations during emergency department (ED) stay for proper diagnosis. This high index of suspicion is crucial to avoid missing the potentially devastating aortic diagnosis. Here, we present a 59-year-old male who presented with chest pain and was ultimately diagnosed with a rare aortic bifurcation saddle thrombus causing acute aortic occlusion. This diagnosis, although rare, highlights a more common point that all patients should be reevaluated for an acute aorta, especially when diagnostic clues are present. The diagnosis was found only because of a thorough reevaluation. Missing the diagnosis would have resulted in death or lifetime dependence on hemodialysis.

Loperamide Overdose.

In light of the opioid epidemic, cardiac complications following a loperamide overdose are a growing concern for patients presenting to the emergency department (ED). Here, we present the case of a 35-year-old male with long QT syndrome who presented following a loperamide overdose and was receiving multiple shocks because of the resulting arrhythmias and electrolyte disturbances. It is necessary for emergency physicians to be aware of loperamide overdoses because cases have been increasing over the past several years and the cardiac complications can be life-threatening.

Paroxysmal Supraventricular Tachycardia.

Supraventricular tachycardia is a common emergency department (ED) pathology that frequently leads to hospital admission, but this may not be necessary in all cases. Here, we present a supraventricular tachycardia patient who was discharged from the ED after vagal maneuvers. This case demonstrates evidence that judicious emergency physicians can discharge supraventricular tachycardia patients home safely and gives impetus for a data-driven protocol for discharging these patients.

Cognitive Errors and Risks Associated with Provider Handoffs.

The emergency department is a challenging environment to practice medicine, primarily due to the pace and logistics of practicing emergency medicine. Cognitive errors and provider handoffs can lead to poor patient outcomes. By acknowledging and addressing cognitive errors, including premature closure, anchoring, and diagnosis momentum, we can potentially improve patient care. Additionally, by completing thorough, yet efficient sign-outs, as per The American College of Emergency Physicians' (ACEP) "Safer Sign Out Protocol," the chances of a poor outcome are further reduced. Below, a case of "migraine headache" is presented, highlighting cognitive errors and the risks associated with provider hand-offs in the emergency department.