Eric S. Nadel

Elevated plasma eotaxin levels in patients with acute asthma.

BACKGROUND The eosinophil chemotactic and activating effects of eotaxin and the known association of eosinophils with asthma suggest that eotaxin expression is increased during asthma exacerbations. OBJECTIVE We sought to determine whether plasma eotaxin levels are elevated in patients presenting for emergency treatment of acute asthma and to correlate eotaxin levels with disease activity and responses to treatment. METHODS A case-control study of plasma eotaxin levels was performed in the 46 patients who presented for emergency asthma treatment and 133 age-, sex-, and ethnicity-matched subjects with stable asthma. RESULTS Plasma eotaxin levels were significantly higher in 46 patients with acute asthma symptoms and airflow obstruction (520 pg/mL [250, 1100 pg/mL]; geometric mean [-1 SD, +1 SD]) than in 133 subjects with stable asthma (350 pg/mL [190, 620 pg/mL]; P =.0008). Among the patients with emergency asthma flares, those who responded to asthma treatment with an increase in peak expiratory flow rate by an amount equal to at least 20% of their predicted normal value had lower eotaxin levels than those who did not (410 pg/mL [210, 800 pg/mL] and 660 pg/mL [300, 1480 pg/mL], respectively; P =.04). CONCLUSION These findings imply that eotaxin either is mechanistically involved in acute asthma or serves as a biomarker for activity of the CCR3 receptor ligand system, which is functionally linked to asthma.

Insulin binding to monocytes in trained athletes: changes in the resting state and after exercise.

Insulin binding to monocytes was examined in trained athletes (long distance runners) and in sedentary control subjects in the resting state and after 3 h of exercise at 40% of maximal aerobic power. At rest, specific binding of 125-I-insulin to monocytes was 69% higher in athletes than in sedentary controls and correlated with maximal aerobic power. The increase in insulin binding was primarily due to an increase in binding capacity. During acute exercise, insulin binding fell by 31% in athletes but rose by 35% in controls. The athletes had a smaller decline in plasma glucose and a lower respiratory exchange ratio during exercise than did controls. We conclude that physical training increases insulin binding to monocytes in the resting state but results in a fall in insulin binding during acute exercise. Changes in insulin binding in athletes thus may account for augmented insulin sensitivity at rest as well as a greater shift from carbohydrate to fat usage during exercise than is observed in untrained controls.

Plagiarism in Residency Application Essays

BACKGROUND Anecdotal reports suggest that some residency application essays contain plagiarized content. OBJECTIVE To determine the prevalence of plagiarism in a large cohort of residency application essays. DESIGN Retrospective cohort study. SETTING 4975 application essays submitted to residency programs at a single large academic medical center between 1 September 2005 and 22 March 2007. MEASUREMENTS Specialized software was used to compare residency application essays with a database of Internet pages, published works, and previously submitted essays and the percentage of the submission matching another source was calculated. A match of more than 10% to an existing work was defined as evidence of plagiarism. RESULTS Evidence of plagiarism was found in 5.2% (95% CI, 4.6% to 5.9%) of essays. The essays of non-U.S. citizens were more likely to demonstrate evidence of plagiarism. Other characteristics associated with the prevalence of plagiarism included medical school location outside the United States and Canada; previous residency or fellowship; lack of research experience, volunteer experience, or publications; a low United States Medical Licensing Examination Step 1 score; and non-membership in the Alpha Omega Alpha Honor Medical Society. LIMITATIONS The software database is probably incomplete, the 10%-match threshold for defining plagiarism has not been statistically validated, and the study was confined to applicants to 1 institution. Evidence of matching content in an essay cannot be used to infer the applicants intent and is not sensitive to variations in the cultural context of copying in some societies. CONCLUSION Evidence of plagiarism in residency application essays is more common in international applicants but was found in those by applicants to all specialty programs, from all medical school types, and even among applicants with significant academic honors. PRIMARY FUNDING SOURCE No external funding.

Doctors in acute and longitudinal care specialties emphasise different professional attributes: implications for training programmes

Objectives  Organised medicine mandates that professionalism be taught during specialty training. This study’s primary objective was to determine the relative importance that doctors in different specialties place on different attributes of a medical professional.

Incorporating simulation into a residency curriculum.

The integration of simulation into a medical postgraduate curriculum requires informed implementation in ways that take advantage of simulations unique ability to facilitate guided application of new knowledge. It requires review of all objectives of the training program to ensure that each of these is mapped to the best possible learning method. To take maximum advantage of the training enhancements made possible by medical simulation, it must be integrated into the learning environment, not simply added on. This requires extensive reorganization of the resident didactic schedule. Simulation planning is supported by clear learning objectives that define the goals of the session, promote learner investment in active participation and allow for structured feedback for individual growth. Teaching to specific objectives using simulation requires an increased time commitment from teaching faculty and careful logistical planning to facilitate flow of learners through a series of simulations in ways that maximize learning. When applied appropriately, simulation offers a unique opportunity for learners to acquire and apply new knowledge under direct supervision in ways that complement the rest of the educational curriculum. In addition, simulation can improve the learning environment and morale of residents, provide additional methods of resident evaluation, and facilitate the introduction of new technologies and procedures into the clinical environment.

Tricyclic Antidepressant Overdose

Q a a r. Pooja Agrawal: Today’s case is that of a 64-year-old oman who was brought in to the Emergency Department y Emergency Medical Services after an apparent suiide attempt. The patient was upset that her husband was till communicating with his ex-wife, who lived in their uilding. After being involved in a verbal altercation ith this woman, the patient stated that she wanted to ie, and subsequently ingested a handful of pills. After uestioning, it was determined that she had taken over 40 ills of 50 mg nortriptylene 2 h before presenting to the mergency Department. She denied ingesting anything lse. She was, at this point, asymptomatic. The past medical history was significant for depresion, hypertension, type 2 diabetes, and mild chronic bstructive pulmonary disease. She had no personal hisory of syncope or coronary disease. The family history as non-contributory; there was no history of sudden nexplained death. Medications included aspirin, chloriazepoxide, hydrochlorthiazide, lisinopril, metformin, someprazole, nortriptyline, tramadol, and simvastatin. here were no recent fevers, illnesses, or trauma. Vital signs were: temperature 36.4°C (97.5°F), heart ate 95 beats/min, blood pressure 160/72 mm Hg, respiatory rate 16 breaths/min, and oxygen saturation 95% on oom air. Initially, the patient appeared agitated and onfused, and subsequently became more somnolent ith shallow breathing. Physical examination revealed o evidence of head injury. Pupils were equal, round, and eactive to light. The neck was supple without meningeal igns. Heart sounds were rapid and regular with no urmurs, rubs, or gallops. The lungs were clear bilaterally o auscultation. The abdomen was soft, with no distenion, tenderness, or guarding. Extremities were warm and ry without rash or swelling. There were no track marks. a

Abdominal pain in first trimester pregnancy

Dr. Todd Thomsen: Today’s case is that of a 6-week pregnant 37-year-old woman with a chief complaint of severe abdominal pain. She was feeling well until the morning of admission, when she experienced the acute onset of severe lower abdominal and pelvic pain. She described the pain as sharp, constant and severe. Shortly after the onset of the pain, she felt lightheaded and had several near-syncopal episodes. There was no malaise, anorexia or dull abdominal pain, and she denied recent trauma, nausea, vomiting, diarrhea, dysuria, flank pain, fever or chills. Her last bowel movement was earlier that morning and was normal. She had eaten a light breakfast of toast and juice several hours before the pain had begun. Dr. Nathan Mick: While the differential diagnosis of abdominal pain is large, the first diagnosis to consider in a woman in her first trimester is ectopic pregnancy. Can you tell us more about her obstetrical history? Was she experiencing any vaginal bleeding? Dr. Thomsen: The patient was G2P1. Her first pregnancy was approximately 10 years ago and was without complications. The current pregnancy was a result of in vitro fertilization (IVF), and three embryos had been transferred into her uterus 6 weeks prior to her Emergency Department (ED) visit. The cause of her infertility was unknown, and she had no history of tubal surgery or pelvic inflammatory disease. An ultrasound performed 1 week prior to presentation showed a normal 5-week-old intrauterine pregnancy (IUP) with a fetal pole, as well as a second intrauterine gestational sac without a fetal pole. No adnexal abnormalities were noted. The patient denied any vaginal bleeding during the course of the current pregnancy. Dr. Peter Pang: Are there any other significant factors in her medical or surgical history? Dr. Thomsen: She denied any chronic medical problems and had no previous surgeries. A prenatal vitamin supplement was her only medication and she had no drug allergies. She denied the use of alcohol, tobacco and illicit substances. Upon our initial evaluation, the patient was pale, profusely diaphoretic, and in obvious distress; she preferred to lay motionless on the gurney, as any movement seemed to exacerbate her symptoms. Vital signs were as follows: temperature 37.2°C (99.0°F), heart rate 126 beats per minute, systolic blood pressure 68 mm Hg, respiratory rate 22 breaths per minute, oxygen saturation 98% on 100% oxygen via face mask. The head and neck examinations were unremarkable. The lungs were clear. Cardiac examination revealed a normal S1 and S2 without a murmur or gallop. The abdominal musculature was held tight with voluntary and involuntary guarding; there was exquisite tenderness to palpation in all four quadrants and rebound tenderness was also present. The pelvic examination revealed a closed os with no vaginal bleeding or discharge. There was bilateral adnexal ten-

Horner's Syndrome, Hoarseness, and Unsteady Gait

*Harvard Affiliated Emergency Medicine Residency, Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, Founders 114, Fruit Street, Boston, MA 02114

Hyperglycemic hyperosmolar nonketotic coma.

Dr. Michael Filbin: Today’s case is that of a 46-yearold woman found unconscious on the floor of her apartment by her boyfriend who immediately called 911. Upon paramedic arrival the patient was noted to be unresponsive, lying on the bedroom floor. The boyfriend told paramedics that she had a history of bipolar disorder for which she took Valproic Acid. She had not been depressed recently and had never made a suicide attempt in the past. She had no known drug allergies. She did not smoke, drink alcohol, or use illicit drugs. The vital signs on EMS arrival included a heart rate of 148 beats per minute (bpm), blood pressure of 90/60 mm Hg, and shallow respirations of 14 breaths per minute. The Glascow Coma Scale was noted to be 4, with eyes opening to painful stimulus but without verbal or motor response. Dr. Eric Nadel: Are there any questions or comments at this point? Dr. Theodore Benzer: In a 46-year-old female found unresponsive with a psychiatric history, a medication overdose is a likely etiology. Did you ask the medics whether empty pill bottles were evident at the scene? Valproic Acid in overdose leads to depressed consciousness and eventual coma, although I wouldn’t expect it to account for such a rapid heart rate. In any comatose patient, definitive airway control is of primary importance, and I would strongly consider immediate endotracheal intubation in this woman. I would also advocate cardiac monitoring to elucidate the nature of the tachycardia in addition to rapid determination of the blood glucose level. Empiric naloxone also should be given at this point. Dr. Filbin: There were no pills missing from her Valproic Acid bottle, and there was no evidence in the home that would suggest a toxic ingestion. The patient was next placed on a cardiac monitor by the paramedics and was found to have ventricular tachycardia (VT) at a rate of approximately 150 bpm (Figure 1). An 18-gauge intravenous (IV) line was placed and 500 cc of normal saline was administered as a bolus. Glucometry showed a blood glucose level exceeding 500 mg/dL. Lidocaine 100 mg IV was administered, and after 2 min she converted to a sinus rhythm at approximately 70 bpm (Figure 2). Her mental status remained depressed, and she was intubated for airway protection without complication. During transport to the hospital, she had another episode of VT that again resolved with an additional 100 mg bolus of lidocaine IV. A lidocaine drip was started at 2 mg per minute IV. Dr. David Brown: The paramedics might have initially opted for immediate synchronized cardioversion in this patient with VT, hypotension, and altered mental status. If medications are chosen as primary therapy, another option would have been to administer amiodarone, which recently has been added to the Advanced Cardiovascular Life Support (ACLS) guidelines for the management of VT and wide complex tachycardia of

Morbidity and Mortality Conference in Emergency Medicine Residencies and the Culture of Safety

Introduction Morbidity and mortality conferences (M+M) are a traditional part of residency training and mandated by the Accreditation Counsel of Graduate Medical Education. This study’s objective was to determine the goals, structure, and the prevalence of practices that foster strong safety cultures in the M+Ms of U.S. emergency medicine (EM) residency programs. Methods The authors conducted a national survey of U.S. EM residency program directors. The survey instrument evaluated five domains of M+M (Organization and Infrastructure; Case Finding; Case Selection; Presentation; and Follow up) based on the validated Agency for Healthcare Research & Quality Safety Culture survey. Results There was an 80% (151/188) response rate. The primary objectives of M+M were discussing adverse outcomes (53/151, 35%), identifying systems errors (47/151, 31%) and identifying cognitive errors (26/151, 17%). Fifty-six percent (84/151) of institutions have anonymous case submission, with 10% (15/151) maintaining complete anonymity during the presentation and 21% (31/151) maintaining partial anonymity. Forty-seven percent (71/151) of programs report a formal process to follow up on systems issues identified at M+M. Forty-four percent (67/151) of programs report regular debriefing with residents who have had their cases presented. Conclusion The structure and goals of M+Ms in EM residencies vary widely. Many programs lack features of M+M that promote a non-punitive response to error, such as anonymity. Other programs lack features that support strong safety cultures, such as following up on systems issues or reporting back to residents on improvements. Further research is warranted to determine if M+M structure is related to patient safety culture in residency programs.