Alex Koyfman

Student Objectives and Learning Experiences in a Global Health Elective

International health electives offer unique experiences for medical students to develop clinical skills and cultural competencies in unique and diverse environments. Medical students have been increasingly pursuing these learning opportunities despite the challenges. However, their goals in pursuing these opportunities and the relation between their learning objectives and actual experiences have not been studied adequately. It is important to assess these programs based on student objectives and whether those objectives are met. Thirty-seven medical students from five cohorts at a US medical school completed pre-post questionnaires regarding their global health elective objectives and learning experiences. The questionnaires included mostly open-ended questions and a Likert-scale rating of their overall experience. Qualitative thematic analysis involved inductive coding and followed a content-driven immersion-crystallization approach. Quantitative program evaluation measures yielded descriptive statistics. Five general objectives and four types of learning experiences were identified. Student objectives were: (1) to observe the practice and organization of health care in another country; (2) improve medical/surgical skills; (3) improve language skills; (4) learn about another culture; and (5) deepen knowledge of infectious diseases. All of their objectives were achieved. Moreover, one learning theme, “self-reflection and personal growth,” was not a student objective. Quantitative assessment showed that most students had a favorable elective experience. Program challenges were also identified. Students in a global health elective were able to fulfill self-identified learning objectives, while also gaining other unexpected yet important lessons. Students’ learning objectives also should be considered in evaluating learning experiences in international health electives.

Review of Recently Approved Alternatives to Anticoagulation with Warfarin for Emergency Clinicians

BACKGROUND Dabigatran and rivaroxaban are novel anticoagulants that have been approved for the prevention of thromboembolic events in atrial fibrillation. These medications are attractive to both patients and clinicians, as, unlike warfarin, they do not require laboratory monitoring or dietary restrictions. However, they carry bleeding risks similar to that of warfarin and are without a reliable reversal agent. OBJECTIVES The objectives of this article are to 1) summarize the pivotal trials leading to the U.S. Food and Drug Administration approvals of dabigatran (Pradaxa; Boehringer Ingelheim, Ridgefield, CT) and rivaroxaban (Xarelto; Janssen Pharmaceuticals, Inc., Titusville, NJ); 2) present the limited data available regarding the management of bleeding patients on these agents; and 3) provide suggestions to guide emergency providers given the limited data. DISCUSSION Dabigatran and rivaroxaban were approved based on large, non-inferiority trials comparing the new agents to warfarin with stroke or systemic embolism as the primary outcome. Traditional coagulation studies cannot be used to determine the degree of anti-coagulation produced by these agents. Fresh frozen plasma is unlikely to be effective in patients on these drugs who are acutely bleeding. Prothrombin complex concentrate can be considered in patients on rivaroxaban. Dabigatran is renally cleared, so dabigatran could be removed by hemodialysis. Theoretically, DDAVP (Sanofi-Aventis U.S. LLC, Bridgewater, NJ), aminocaproic acid, tranexamic acid, or recombinant activated factor VII could also be used in an attempt to control bleeding. CONCLUSION There is a need for assays for the degree of anticoagulation produced by drugs such as dabigatran and rivaroxaban. Additionally, studies are needed to evaluate reversal agents that could be effective in the setting of acute bleeding.

Thrombotic thrombocytopenic purpura.

In 1924, Dr Eli Moschcowitz described a 16-year-old adolescent girl with abrupt onset of petechiae, hemolytic anemia, followed by paralysis, coma, and death. Autopsy showed widespread hyaline thrombi in the terminal arterioles and capillaries of various organs. The syndrome described by Moschowitz is now known as thrombotic thrombocytopenic purpura.

Does Calcium Administration During Cardiopulmonary Resuscitation Improve Survival for Patients in Cardiac Arrest

TUDY SELECTION his review was conducted to pdate the Guidelines on ardiopulmonary Resuscitation nd Emergency Cardiac Care, using he 2010 International Liaison ommittee on Resuscitation ILCOR) evidence evaluation rocess. Forty-eight articles were etrieved but only 10 included. ach included article matched one f the 5 levels of evidence reported y ILCOR (Table). Editorial articles, bstracts, reviews, commentaries, nd guidelines were excluded.

A taste of periodic fever syndromes.

Abstract Periodic fevers are acquired or inherited disorders of innate immunity, which were first described in the 1940s. The patients are typically young at onset and have regularly recurring fevers for a few days to a few weeks with systemic inflammatory symptoms that are interrupted by symptom-free periods. There is a variety of clinical manifestations including gastrointestinal complaints, myalgias, arthralgias, and rash. A differential diagnosis in these patients may include recurrent infections, other inflammatory disorders, and neoplastic disease. This clinical review focuses on a sample of autoinflammatory disorders including familial Mediterranean fever, tumor necrosis factor receptor 1–associated periodic syndrome, hyperimmunoglobulinemia D syndrome, the cryopyrin-associated periodic syndrome, and periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome. We review the basics, pertinent clinical and laboratory features, and management of each entity.

In Patients With Acute Ischemic Stroke, Do Different Thrombolytic Doses, Agents, or Routes of Administration Lead to Different Outcomes?

IAS AND DATA ANALYSIS o assess study quality and risk of ias, randomization, allocation oncealment, blinding, and ntention-to-treat analysis data ere collected. Primary outcome as functional outcome at the end f follow-up. An intention-to-treat nalysis was performed for econdary outcomes: early and otal deaths at the end of follow-up, ymptomatic and fatal intracranial leeding events, and major xtracranial bleeding events.