Simulation-based assessment for the emergency medicine milestones: a national survey of simulation experts and program directors

The focus of outcome-based education has shifted from the process of training to the end“product”of education.This has necessitated a reframing of the teaching,learning,and assessment.Therefore,in 2013,the Accreditation Council for Graduate Medical Education(ACGME)implemented the educational milestones for all accredited residencies and fellowship programs.[1]The milestones have been described as“developmentally based,specialty-specific achievements that residents are expected to demonstrate at established intervals as they progress through training.”[1]Milestones are based on the six core competencies established by the ACGME and American Board of Medical Specialties(ABMS),which consist of medical knowledge(MK),patient care(PC),interpersonal and communication skills(ICS),practice-based learning and improvement(PBLI),professionalism(PROF),and systems-based practice(SBP).[2,3]ACGME,in conjunction with the American Board of Emergency Medicine(ABEM),drafted 23 detailed subcompetencies relevant to emergency medicine(EM).[4]

Assessment of Online Transgender Healthcare Teaching Modules for Internal Medicine Residents and Fellows

Background: Transgender healthcare is not a formal learning requirement in Internal Medicine residency or fellowship. The National LGBTQ Task Force appealed to urgently train clinicians on the effective care of transgender patients. Few studies address the successful implementation of transgender healthcare teaching and education in graduate medical education. Purpose: The purpose was to design an online asynchronous curriculum to address the need for improved transgender healthcare education in graduate medical education and assess change in knowledge and comfort in transgender healthcare for residents and fellow learners. Methods: A 6-module curriculum was developed using established guidelines and ACGME competencies as a framework for content. To assess curriculum effectiveness, participants received anonymous pre- and post-curriculum surveys which included a multiple-choice knowledge assessment, Likert scale comfort questions focusing on healthcare skills, and open-ended feedback questions. Results: Twenty-six internal medicine residents and fellows participated in the curriculum (2022-2023). There was a 69% post-survey response rate. Participants improved their gender-affirming knowledge after completing the curriculum (p Conclusion: This online curriculum was successful in increasing knowledge and comfort in transgender care for IM residents and fellows. It provides a promising framework to address this gap in curricular content.

Subclinical hepatitis E virus genotype 1 infection:The concept of“dynamic human reservoir”

Hepatitis E virus(HEV)is hyperendemic in South Asia and Africa accounting for half of total Global HEV burden.There are eight genotypes of HEV.Among them,the four common ones known to infect humans,genotypes 1 and 2 are prevalent in the developing world and genotypes 3 and 4 are causing challenge in the industrialized world.Asymptomatic HEV viremia in the general population,especially among blood donors,has been reported in the literature worldwide.The clinical implications related to this asymptomatic viremia are unclear and need further exploration.Detection of viremia due to HEV genotype 1 infection,apparently among healthy blood donors is also reported without much knowledge about its infection rate.Similarly,while HEV genotype 3 is known to be transmitted via blood transfusion in humans and has been subjected to screening in many European nations,instances of transmission have also been documented albeit without significant clinical consequences.Epidemiology of HEV genotype 1 in endemic areas often show waxing and waning pattern.Occasional sporadic occurrence of HEV infection interrupted by outbreaks have been frequently seen.In absence of known animal reservoir,where HEV exists in between outbreak is a mystery that needs further exploration.However,occurrence of asymptomatic HEV viremia due to HEV genotype 1 during epidemiologically quiescent period may explain that this phenomenon may act as a dynamic reservoir.Since HEV genotype 1 infection cannot cause chronicity,subclinical transient infection and transmission of virus might be the reason it sustains in interepidemic period.This might be the similar phenomenon with SARS COVID-19 corona virus infection which is circulating worldwide in distinct phases with peaks and plateaus despite vaccination against it.In view of existing evidence,we propose the concept of“Dynamic Human Reservoir.”Quiescent subclinical infection of HEV without any clinical consequences and subsequent transmission may contribute to the existence of the virus in a community.The potential for transmitting HEV infection by asymptomatic HEV infected individuals by fecal shedding of virus has not been reported in literature.This missing link may be a key to Pandora's box in understanding epidemiology of HEV infection in genotype 1 predominant region.

Patient care during interfacility transport:a narrative review of managing diverse disease states

BACKGROUND:When critically ill patients require specialized treatment that exceeds the capability of the index hospitals,patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care.Therefore,appropriate and efficient care for patients during the process of transport between two hospitals(interfacility transfer)is an essential part of patient care.While medical adverse events may occur during the interfacility transfer process,there have not been evidence-based guidelines regarding the equipment or the practice for patient care during transport.METHODS:We conducted searches from the PubMed,Cumulative Index of Nursing and Allied Health(CINAHL),and Scopus databases up to June 2022.Two reviewers independently screened the titles and abstracts for eligibility.Studies that were not in the English language and did not involve critically ill patients were excluded.RESULTS:The search identified 75 articles,and we included 48 studies for our narrative review.Most studies were observational studies.CONCLUSION:The review provided the current evidence-based management of diverse disease states during the interfacility transfer process,such as proning positioning for respiratory failure,extracorporeal membrane oxygenation(ECMO),obstetric emergencies,and hypertensive emergencies(aortic dissection and spontaneous intracranial hemorrhage).

Functional phenotyping of microglia highlights the dark relationship between chronic traumatic brain injury and normal age-related pathology

Traumatic brain injury(TBI) is a major cause of death and disability worldwide. Age-related TBI differences demonstrate the third peak of prevalence and incidence of TBI within the elderly population. This is due to the elderly being at a higher risk of sustaining falls, which have been identified as the main cause(40–50%) of TBI.

Rural-urban differences in distributions and determinants of facility delivery among women in Bangladesh

Introduction:The utilization of facility delivery is crucial to achieve sustainable development goals by reducing maternal and neonatal deaths.This study aimed to compare the distributions and determinants of childbirth in health facilities in urban and rural regions of Bangladesh.Methods:Cross-sectional data from the 2017-2018 Bangladesh Demographic and Health Survey were analyzed.Multilevel logistic regression was applied.Results:A total of 4751 women were included in the analyses.Only 50%of childbirths took place in health facilities,63.4%and 44.6%in urban and rural regions,respectively.Overall,the odds of the association between facility delivery and the studied factors were similar.Multiparous women had significantly lower odds of facility delivery in both rural(adjusted odds ratio[AOR]=0.3,95%confidence interval[CI]:0.2 to 0.5)and urban(AOR=0.2,95%CI:0.1 to 0.5)regions.In both regions,women with higher education levels,highly educated husbands,antenatal care(ANC),and higher wealth indexes had significantly higher odds of facility delivery.Conclusion:Several common associated factors were identified.However,differences were observed regarding distributions of these factors.The differences in facility delivery utilization could result from lower ANC utilization,socioeconomic status,and transportation facilities in rural regions than urban regions;therefore,improving these conditions could increase facility delivery in these regions.

Utilizing Anesthesiologists, Emergency and Critical Care Physicians with Telemedicine Monitoring to Develop Intubation and Ventilation Services in an Intensive Care Unit in the Austere Medical Environment: A Case Series. Expansion of the EP/CC GAS Project

Background: Significant resource constraints and critical care training gaps are responsible for the limited development of intensive care units (ICUs) in resource limited settings. We describe the implementation of an ICU in Haiti and report the successes and difficulties encountered throughout the process. We present a consecutive case series investigating an anesthesiologist, emergency, and critical care physician implemented endotracheal intubation and mechanical ventilation protocol in an austere environment with the assistance of telemedicine. Methods: A consecutive case series of fifteen patients admitted to an ICU at St. Luc Hospital located in Portau-Prince, Haiti, between the months of February 2012 to April 2014 is reported. Causes of respiratory failure and the clinical course are presented. Patients were followed to either death or discharge. Results: Fifteen patients (eight women and seven men) were included in the study with an average age of 37.7 years. The mean duration of ventilation was three days. Of the fifteen patients intubated, five patients (33.3%) survived and were discharged from the ICU. Of the five surviving patients, two were intubated for status epilepticus, one for status asthmaticus and one for hyperosmolar coma associated with intracerebral hemorrhage. Of the patients dying on the ventilator, four patients died from pneumonia, two from renal failure, and one from tetanus. The remaining three died from strokes and cardiac arrests. Conclusions: Mortality of mechanically ventilated patients in a resource-limited country is significant. Focused training in core critical care skills aimed at increasing the endotracheal intubation and ventilatory management capacity of local medical staff should be a priority in order to continue to develop ICUs in these austere environments. Collaborative educational and training efforts directed by anesthesiologists, emergency, and critical care physicians, and aided by telemedicine can facilitate realizing this goal.

Introducing the Journal of Integrative Medicine

At the beginning of this New Year of 2013, we are very pleased to present the English edition of the Journal of Integrative Medicine （JIM）, a PubMed-indexed, peer-reviewed, open-access journal on integrative medicine. The JIM is a continuation of the former Chinese-language journal, the Journal of Chinese Integrative Medicine （JCIM）, established in 2003 and published in Shanghai. Integrative medicine, grounded in patient-centered, evidence-based practice, incorporates the broad spectrum of complementary and alternative medicine （CAM） and includes acupuncture and traditional Chinese medicine, Ayurveda medicine, herbal medicine, homeopathy, nutrition, chiropractic, mind-body medicine, taichi, qigong, and meditation, among other professions. In the past two decades, CAM has become one of the fastest growing branches of health care. CAM now commands attention worldwide and is rapidly being integrated into conventional medicine. China is the country in the world that has great number of scientists doing clinical and research work on integrative medicine. With this new, English-language publication, we are committed to make JIM an international platform for high-quality CAM papers and an open forum in which the different professions and international scholarly communities can exchange views, share research and their clinical experience, discuss CAM education, and confer about issues and problems in our various disciplines and in CAM as a whole in order to promote integrative medicine.

Breast cancer resistance protein(BCRP/ABCG2):its role in multidrug resistance and regulation of its gene expression

Breast cancer resistance protein(BCRP)/ATP-binding cassette subfamily G member 2(ABCG2) is an ATP-binding cassette(ABC) transporter identified as a molecular cause of multidrug resistance(MDR) in diverse cancer cells.BCRP physiologically functions as a part of a self-defense mechanism for the organism;it enhances elimination of toxic xenobiotic substances and harmful agents in the gut and biliary tract,as well as through the blood-brain,placental,and possibly blood-testis barriers.BCRP recognizes and transports numerous anticancer drugs including conventional chemotherapeutic and targeted small therapeutic molecules relatively new in clinical use.Thus,BCRP expression in cancer cells directly causes MDR by active efflux of anticancer drugs.Because BCRP is also known to be a stem cell marker,its expression in cancer cells could be a manifestation of metabolic and signaling pathways that confer multiple mechanisms of drug resistance,self-renewal(stemness),and invasiveness(aggressiveness),and thereby impart a poor prognosis.Therefore,blocking BCRP-mediated active efflux may provide a therapeutic benefit for cancers.Delineating the precise molecular mechanisms for BCRP gene expression may lead to identification of a novel molecular target to modulate BCRP-mediated MDR.Current evidence suggests that BCRP gene transcription is regulated by a number of trans-acting elements including hypoxia inducible factor 1α,estrogen receptor,and peroxisome proliferator-activated receptor.Furthermore,alternative promoter usage,demethylation of the BCRP promoter,and histone modification are likely associated with drug-induced BCRP overexpression in cancer cells.Finally,PI3K/AKT signaling may play a critical role in modulating BCRP function under a variety of conditions.These biological events seem involved in a complicated manner.Untangling the events would be an essential first step to developing a method to modulate BCRP function to aid patients with cancer.This review will present a synopsis of the impact of BCRP-mediated MDR in cancer cells,and the molecular mechanisms of acquired MDR currently postulated in a variety of human cancers.

Roles of micro RNA-140 in stem cell-associated early stage breast cancer

An increasing body of evidence supports a stepwise model for progression of breast cancer from ductal carcinoma in situ(DCIS) to invasive ductal carcinoma(IDC). Due to the high level of DCIS heterogeneity, we cannot currently predict which patients are at highest risk for disease recurrence or progression. The mechanisms of progression are still largely unknown, however cancer stem cell populations in DCIS lesions may serve as malignant precursor cells intimately involved in progression. While genetic and epigenetic alterations found in DCIS are often shared by IDC, m RNA and mi RNA expression profiles are significantly altered. Therapeutic targeting of cancer stem cell pathways and differentially expressed mi RNA could have significant clinical benefit. As tumor grade increases, mi RNA-140 is progressively downregulated. mi R-140 plays an important tumor suppressive role in the Wnt, SOX2 and SOX9 stem cell regulator pathways. Downregulation of mi R-140 removes inhibition of these pathways, leading to higher cancer stem cell populations and breast cancer progression. mi R-140 downregulation is mediated through both an estrogen response element in the mi R-140 promoter region and differential methylation of Cp G islands. These mechanisms are novel targets for epigenetic therapy to activate tumor suppressor signaling via mi R-140. Additionally, we briefly explored the emerging role of exosomes in mediating intercellular mi R-140 signaling. The purpose of this review is to examine the cancer stem cell signaling pathways involved in breast cancer progression, and the role of dysregulation of mi R-140 in regulating DCIS to IDC transition.

Mechanisms of the alternative activation of macrophages and non-coding RNAs in the development of radiation-induced lung fibrosis

Radiation-induced lung fibrosis(RILF) is a common side effect of thoracic irradiation therapy and leads to high mortality rates after cancer treatment. Radiation injury induces inflammatory M1 macrophage polarization leading to radiation pneumonitis, the first stage of RILF progression. Fibrosis occurs due to the transition of M1 macrophages to the anti-inflammatory pro-fibrotic M2 phenotype, and the resulting imbalance of macrophage regulated inflammatory signaling. Non-coding RNA signaling has been shown to play a large role in the regulation of the M2 mediated signaling pathways that are associated with the development and progression of fibrosis. While many studies show the link between M2 macrophages and fibrosis, there are only a few that explore their distinct role and the regulation of their signaling by non-coding RNA in RILF. In this review we summarize the current body of knowledge describing the roles of M2 macrophages in RILF, with an emphasis on the expression and functions of non-coding RNAs.

One-year water-ageing of calcium phosphate composite containing nano-silver and quaternary ammonium to inhibit biofilms

Dental composites are commonly used restorative materials; however, secondary caries due to biofilm acids remains a major problem. The objectives of this study were （1） to develop a composite containing quaternary ammonium dimethacrylate （QADM）, nanoparticles of silver （NAg）, and nanoparticles of amorphous calcium phosphate （NACP）, and （2） to conduct the first investigation of the mechanical properties, biofilm response and acid production vs water-ageing time from 1 day to 12 months. A 4 x 5 design was utilized, with four composites （NACP-QADM composite, NACP-NAg composite, NACP-QADM-NAg composite, and a commercial control composite）, and five water-ageing time periods （1 day, and 3, 6, 9, and 12 months）. After each water- ageing period, the mechanical properties of the resins were measured in a three-point flexure, and antibacterial properties were tested via a dental plaque biofilm model using human saliva as an inoculum. After 12 months of water-ageing, NACP-QADM- NAg had a flexural strength and elastic modulus matching those of the commercial control （P〉 0.1）. Incorporation of QADM or NAg into the NACP composite greatly reduced biofilm viability, metabolic activity and acid production. A composite containing both QADM and NAg possessed a stronger antibacterial capability than one with QADM or NAg alone （P〈0.05）. The anti-biofilm activity was maintained after 12 months of water-ageing and showed no significant decrease with increasing time （P〉0.1）. In conclusion, the NACP-QADM-NAg composite decreased biofilm viability and lactic acid production, while matching the load- bearing capability of a commercial composite. There was no decrease in its antibacterial properties after 1 year of water-ageing. The durable antibacterial and mechanical properties indicate that NACP-QADM-NAg composites may be useful in dental restorations to combat caries.

Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection

BACKGROUND: Acute aortic dissection(AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act(EMTALA) is crucial. The study assessed emergency providers(EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD patients.METHODS: This retrospective study examined adult patients transferred directly from a referring emergency department(ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care(ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance(ADoEMTALA). RESULTS: There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five(36.6%) patients had ADoCC while 166(57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA(IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association(AHA) ED Departure SBP guideline(OR 1.8, 95% CI 1.03–3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care(IDoCC), while receiving continuous infusion was associated with higher risk of IDoEMTALA.CONCLUSION: Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.

Use of biological meshes for abdominal wall reconstruction in highly contaminated fields

Abdominal wall defects and incisional hernias represent a challenging problem. In particular, when a synthetic mesh is applied to contaminated wounds, its removal is required in 50%-90% of cases. Biosynthetic meshes are the newest tool available to surgeons and they could have a role in ventral hernia repair in a potential-ly contaminated field. We describe the use of a sheet of bovine pericardium graft in the reconstruction of abdominal wall defect in two patients. Bovine pericardium graft was placed in the retrorectus space and secured to the anterior abdominal wall using polypropylene sutures in a tension-free manner. We experienced no evidence of recurrence at 4 and 5 years follow-up.

Adipocyte activation of cancer stem cell signaling in breast cancer

Signaling within the tumor microenvironment has a critical role in cancer initiation and progression. Adipocytes, one of the major components of the breast microenvironment,have been shown to provide pro-tumorigenic signals that promote cancer cell proliferation and invasiveness in vitro and tumorigenicity in vivo. Adipocyte secreted factors such as leptin and interleukin-6(IL-6) have a paracrine effect on breast cancer cells. In adipocyte-adjacent breast cancer cells, the leptin and IL-6 signaling pathways activate janus kinase 2/signal transducer and activatorof transcription 5, promoting the epithelial-mesenchymal transition, and upregulating stemness regulators such as Notch, Wnt and the Sex determining region Y-box 2/octamer binding transcription factor 4/Nanog signaling axis. In this review we will summarize the major signaling pathways that regulate cancer stem cells in breast cancer and describe the effects that adipocyte secreted IL-6 and leptin have on breast cancer stem cell signaling. Finally we will introduce a new potential treatment paradigm of inhibiting the adipocyte-breast cancer cell signaling via targeting the IL-6 or leptin pathways.

Prevention of macrovascular complications in patients with type 2 diabetes mellitus: Review of cardiovascular safety and efficacy of newer diabetes medications

Lack of conclusive beneficial effects of strict glycemic control on macrovascular complications has been very frustrating for clinicians involved in care of patients with diabetes mellitus (DM). Highly publicized controversy surrounding cardiovascular (CV) safety of rosiglitazone resulted in major changes in United States Food and Drug Administration policy in 2008 regarding approval process of new antidiabetic medications, which has resulted in revolutionary data from several large CV outcome trials over the last few years. All drugs in glucagon-like peptide-1 receptor agonist (GLP-1 RA) and sodium-glucose cotransporter-2 (SGLT-2) inhibitor classes have shown to be CV safe with heterogeneous results on CV efficacy. Given twofold higher CV disease mortality in patients with DM than without DM, GLP-1 RAs and SGLT-2-inhibitors are important additions to clinician’s armamentarium and should be second line-therapy particularly in patients with T2DM and established atherosclerotic CV disease or high risks for CV disease. Abundance of data and heterogeneity in CV outcome trials results can make it difficult for clinicians, particularly primary care physicians, to stay updated with all the recent evidence. The scope of this comprehensive review will focus on all major CV outcome studies evaluating CV safety and efficacy of GLP-1 RAs and SGLT-2 inhibitors.

Acute drivers of neuroinflammation in traumatic brain injury

Neuroinflammation is initiated as a result of traumatic brain injury and can exacerbate evolving tissue pathology.Immune cells respond to acute signals from damaged cells,initiate neuroinflammation,and drive the pathological consequences over time.Importantly,the mechanism(s)of injury,the location of the immune cells within the brain,and the animal species all contribute to immune cell behavior following traumatic brain injury.Understanding the signals that initiate neuroinflammation and the context in which they appear may be critical for understanding immune cell contributions to pathology and regeneration.Within this paper,we review a number of factors that could affect immune cell behavior acutely following traumatic brain injury.

Neuroendocrine tumors of the gastrointestinal tract: Case reports and literature review

Neuroendocrine tumors(NET)previously called carcinoid tumors are neoplasms of enterochromaffin/neuroendocrine cell origin which display neurosecretory capacity that may result in the carcinoid syndrome.The annual incidence of patients with NET is 8.4 per 100000;yet many NET remain asymptomatic and clinically undetected.A majority of NET follows a benign course;however,some will display malignant characteristics.NET most commonly occur in the gastrointestinal tract(67%)and bronchopulmonary system(25%).Gastrointestinal NET occur within the stomach,small intestine,liver,and rectum.We report a retrospective study of 11 subjects:Eight with benign carcinoid tumors:duodenal bulb(n=2),terminal ileum(n=1),sigmoid colon(n=2),and rectum(n=3);three with malignant carcinoid:liver(n=1)and intra-abdominal site(n=2).The diagnosis,endoscopic images,outcome,treatment and review of the literature are presented.

Operative vs non-operative management of displaced proximal humeral fractures in the elderly: A systematic review and meta-analysis of randomized controlled trials

AIM: To perform a systematic review and meta-analysis comparing operative vs non-operative treatment of displaced proximal humerus fractures in elderly patients.METHODS: A systematic literature search was performed using EMBASE and MEDLINE through the OVID interface,CINAHL,the Cochrane Central Register of Controlled Trials(CENTRAL),Proquest,Web of Science,SAE digital library,and Transportation Research Board's TRID database.Searches of conference proceedings were also conducted.All available randomized controlled trials comparing operative vs non-operative management of displaced three- and four-part proximal humerus fractures in elderly patients were included.The primary outcomes measures included physical function,pain,health related quality of life,mortality,and the re-operation rate.RESULTS: Six randomized controlled trials(n = 287) were included.There was no statistically significant difference in function(MD = 1.72,95%CI:-2.90-6.34,P = 0.47),as measured by the Constant score,between the operative and the non-operative treatment groups.There was no statistically significance difference insecondary outcomes of health related quality of life(standardized MD = 0.27,95%CI:-0.05-0.59,P = 0.09),and mortality(relative risk 1.29,95%CI: 0.50-3.35,P = 0.60).Operative treatment had a statistically significant higher re-operation rate(relative risk 4.09,95%CI: 1.50-11.15,P = 0.006),and statistically significant decreased pain(MD = 1.26,95%CI: 0.02-2.49,P = 0.05).CONCLUSION: There is moderate quality evidence to suggest that there is no difference in functional outcomes between the two treatments.Further high quality randomized controlled trials are required to determine if certain subgroup populations benefit from surgical management.

Lymphoepithelioma-like carcinoma of the breast presenting as breast abscess

Lymphoepithelioma-like carcinoma(LELC) is a rare type of neoplasm in which only twenty cases have been reported in the breast. This type of tumor can be difficult to distinguish from other breast tumors particularly medullary carcinoma and lymphoma in the breast. We present a case of LELC of the breast presenting as an abscess along with a review of the literature. This is the 21 st reported case of LELC of the breast and the first case to present as an abscess. Her clinical picture could have been mistaken for other infectious or inflammatory diseases. Given the potential for favorable outcome, early detection and general knowledge of this neoplasm are essential to expedite treatment for this rare tumor type.