Carol A. Terregino

Endogenous mediators in emergency department patients with presumed sepsis: Are levels associated with progression to severe sepsis and death?

STUDY OBJECTIVE We sought to determine whether levels of the endogenous mediators tumor necrosis factor (TNF)-alpha, interleukin (IL) 6, and nitric oxide (NO) measured in patients with presumed sepsis (systemic inflammatory response syndrome [SIRS] and infection) are different than levels in patients with presumed noninfectious SIRS, whether levels are associated with septic complications, and whether there are potential relationships between mediators. METHODS A prospective, observational tricenter study of a convenience sample of adults presenting to the emergency department meeting Bones criteria for SIRS (any combination of fever or hypothermia, tachycardia, tachypnea, or WBC count aberration) was performed. Mediator levels were determined and associated with deterioration to severe sepsis (hypotension, hypoperfusion, or organ dysfunction) and death in subjects admitted to the hospital with presumed sepsis. RESULTS One hundred eighty subjects with SIRS were enrolled and classified into 3 groups: group 1 (SIRS, presumed infection, admitted; n=108), group 2 (SIRS, presumed infection, discharged; n=27), and group 3 (SIRS, presumed noninfectious, admitted; n=45). Group 1 TNF-alpha and IL-6 levels were significantly higher than those found in the other groups. NO levels for groups 1 and 2 were significantly lower than those for group 3. TNF-alpha and IL-6 levels were higher in the group 1 subjects who had bacteremia or progressed to severe sepsis or death. NO levels were not associated with these outcomes. CONCLUSION ED patients admitted with presumed sepsis have elevated cytokine levels compared with patients with sepsis who are discharged and with those patients with presumed noninfectious SIRS. An association appears to exist between cytokines and subsequent septic complications in these patients. The importance of these measures as clinical predictors for the presence of infection and subsequent septic complications needs to be evaluated.

Core Personal Competencies Important to Entering Students’ Success in Medical School: What Are They and How Could They Be Assessed Early in the Admission Process?

Assessing applicants’ personal competencies in the admission process has proven difficult because there is not an agreed-on set of personal competencies for entering medical students. In addition, there are questions about the measurement properties and costs of currently available assessment tools. The Association of American Medical College’s Innovation Lab Working Group (ILWG) and Admissions Initiative therefore engaged in a multistep, multiyear process to identify personal competencies important to entering students’ success in medical school as well as ways to measure them early in the admission process. To identify core personal competencies, they conducted literature reviews, surveyed U.S and Canadian medical school admission officers, and solicited input from the admission community. To identify tools with the potential to provide data in time for pre-interview screening, they reviewed the higher education and employment literature and evaluated tools’ psychometric properties, group differences, risk of coaching/faking, likely applicant and admission officer reactions, costs, and scalability. This process resulted in a list of nine core personal competencies rated by stakeholders as very or extremely important for entering medical students: ethical responsibility to self and others; reliability and dependability; service orientation; social skills; capacity for improvement; resilience and adaptability; cultural competence; oral communication; and teamwork. The ILWG’s research suggests that some tools hold promise for assessing personal competencies, but the authors caution that none are perfect for all situations. They recommend that multiple tools be used to evaluate information about applicants’ personal competencies in deciding whom to interview.

Selective indications for thoracic and lumbar radiography in blunt trauma.

Abstract Study objective: To determine indications for thoracolumbar radiography. Design: Case series with prospective data collection. Setting: Level I trauma center. Participants: Blunt-trauma victims more than 12 years old who underwent routine thoracic and lumbar radigraphy according to institutional protocol. Patients were classified as group 1, not able to be evaluated clinically (Glasgow Coma Scale score of less than 13, intoxication, intubation, or cervical neurologic deficit); and group 2, able to be evaluated clinically. Results: Twenty-four of 319 patients sustained 25 thoracic or lumbar fractures. Seven of 136 group 1 patients and 17 of 183 group 2 patients had fractures. Eight of 17 patients with pain and 9 of 17 with tenderness had fractures ( P =.001). No group 2 patients without pain, tenderness, thoracic or lumbar neurodeficit, or major distracting injury, including cervical fracture, had fractures. The negative predictive value of pain and tenderness was 95%. Five of 46 patients with spinal fractures at any level had multiple fractures. Conclusion: Blunt-trauma victims who cannot be evaluated clinically should undergo thoracolumbar radiography. Routine radiography may be unnecessary in asymptomatic patients who can be evaluated clinically and who do not have neurologic deficits or distracting injuries. Spinal fracture at any level mandates complete spinal radiography. [Terregino CA, Ross SE, Lipinski MF, Foreman J, Hughes R: Selective indications for thoracic and lumbar radiography in blunt trauma. Ann Emerg Med August 1995;26:126-129.]

Impaired Neutrophil Adherence as an Early Marker of Systemic Inflammatory Response Syndrome and Severe Sepsis

STUDY OBJECTIVE To determine whether neutrophil adherence was altered in the presence of systemic inflammatory response syndrome (SIRS) and infection or severe sepsis. METHODS We conducted a prospective study of a convenience sample of adults presenting to an academic urban ED to be admitted with SIRS and infection or with severe sepsis. Serial phlebotomy was performed in the ED and 12 and 24 hours into the hospital stay. We used an adherence assay that involves adding 1-mL aliquots of heparinized blood to pipettes packed with nylon. Cell count and differential on the eluates and a control tube were carried out to determine the percentage of adhering neutrophils. We reviewed charts for parameters of clinical progression. RESULTS Adherence values among patients with SIRS and severe sepsis were 27% +/- 17% (n = 19) and 13% +/- 16% (n = 4), respectively, significantly less than mean adherence in normal controls (47% +/- 10%; P = .0006 and .0007, ANOVA). Adherence among patients with severe sepsis and those who clinically progressed were not significantly different from that in all SIRS cases. Serial values did not differ from initial values. CONCLUSION Neutrophil adherence was significantly decreased in patients with SIRS and severe sepsis compared with that in normal controls. A larger study enrolling consecutive SIRS subject at risk for severe sepsis may demonstrate whether this assay could be useful in managing sepsis in the ED.

The Effect of Differential Weighting of Academics, Experiences, and Competencies Measured by Multiple Mini Interview (MMI) on Race and Ethnicity of Cohorts Accepted to One Medical School

Purpose To examine whether academic scores, experience scores, and Multiple Mini Interview (MMI) core personal competencies scores vary across applicants’ self-reported ethnicities, and whether changes in weighting of scores would alter the proportion of ethnicities underrepresented in medicine (URIM) in the entering class composition. Method This study analyzed retrospective data from 1,339 applicants to the Rutgers Robert Wood Johnson Medical School interviewed for entering classes 2011–2013. Data analyzed included two academic scores—grade point average (GPA) and Medical College Admission Test (MCAT)—service/clinical/research (SCR) scores, and MMI scores. Independent-samples t tests evaluated whether URIM ethnicities differed from non-URIM across GPA, MCAT, SCR, and MMI scores. A series of “what-if” analyses were conducted to determine whether alternative weighting methods would have changed final admissions decisions and entering class composition. Results URIM applicants had significantly lower GPAs (P < .001), MCATs (P < .001), and SCR scores (P < .001). However, this pattern was not found with MMI score (non-URIM 10.4 [1.6], URIM 10.4 [1.3], P = .55). Alternative weighting analyses show that including academic/experiential scores impacts the percentage of URIM acceptances. URIM acceptance rate declined from 57% (100% MMI) to 43% (10% GPA/10% MCAT/10% SCR/70% MMI), 39% (30% GPA/70% MMI), to as low as 22% (50% MCAT/50% MMI). Conclusions Sole reliance on the MMI for final admissions decisions, after threshold academic/experiential preparation are met, promotes diversity with the accepted applicant pool; weighting of “the numbers” or what is written about the application may decrease the acceptance of URIM applicants.

Comparison of linear-stochastic and nonlinear-deterministic algorithms in the analysis of 15-minute clinical ECGs to predict risk of arrhythmic death.

Objective: Comparative algorithmic evaluation of heartbeat series in low-to-high risk cardiac patients for the prospective prediction of risk of arrhythmic death (AD). Background: Heartbeat variation reflects cardiac autonomic function and risk of AD. Indices based on linear stochastic models are independent risk factors for AD in post-myocardial infarction (post-MI) cohorts. Indices based on nonlinear deterministic models have superior predictability in retrospective data. Methods: Patients were enrolled (N = 397) in three emergency departments upon presenting with chest pain and were determined to be at low-to-high risk of acute MI (>7%). Brief ECGs were recorded (15 min) and R-R intervals assessed by three nonlinear algorithms (PD2i, DFA, and ApEn) and four conventional linear-stochastic measures (SDNN, MNN, 1/f-Slope, LF/HF). Out-of-hospital AD was determined by modified Hinkle–Thaler criteria. Results: All-cause mortality at one-year follow-up was 10.3%, with 7.7% adjudicated to be AD. The sensitivity and relative risk for predicting AD was highest at all time-points for the nonlinear PD2i algorithm (p ≤0.001). The sensitivity at 30 days was 100%, specificity 58%, and relative risk >100 (p ≤0.001); sensitivity at 360 days was 95%, specificity 58%, and relative risk >11.4 (p ≤0.001). Conclusions: Heartbeat analysis by the time-dependent nonlinear PD2i algorithm is comparatively the superior test.

Creative group performances to assess core competencies in a first-year patient-centered medicine course.

Introduction: A novel assessment of systems-based practice and practice-based learning and improvement learning objectives, implemented in a first-year patient-centered medicine course, is qualitatively described. Methods: Student learning communities were asked to creatively demonstrate a problem and solution for health care delivery. Skits, filmed performances, plays, and documentaries were chosen by the students. Video recordings were reviewed for themes and the presence of course competencies. Results: All performances demonstrated not only the index competencies of team work and facilitation of the learning of others, but many other core objectives of the course. The assignment was rated positively both by the faculty and the students, and has been added to the assessment modalities of the course.

University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School.

The Senior Associate Dean for Education is in charge of the Office of Education. (See Figure 1) Those who report to the Senior Associate Dean include the Associate Dean for Education; the Assistant Dean for Educational Programs and Director of the Cognitive Skills Program; the Assistant Dean for Education; and several support staff for curriculum management, clinical skills center, and evaluation. Additional administrators in the Office of Education include the Associate Dean for Student Affairs, the Associate Dean for Admissions, and the Associate Dean for Graduate Medical Education. The Senior Associate Dean for the Regional Campus has a dotted-line reporting structure to the Senior Associate Dean for Education. Virtually all of the faculty administrators are also educators and serve in the role of teacher or course or clerkship directors in different phases of the curriculum.