Millions of patients present to US emergency departments every year with OB/GYN concerns. Emergency medicine trainees must be adequately prepared to care for this population, regardless of how ...commonly they appear in the training environment. We used active learning and gamification principles in this curriculum to increase learner engagement and participation in the material.
We chose OB/GYN topics based on review of Tintinalli's OB/GYN content and the American Board of Emergency Medicine's Model of Clinical Practice. Each session comprised a case-based lecture and review questions using the game-based Kahoot! online software. Pre- and postcurriculum surveys assessed residents' confidence in caring for emergent OB/GYN pathologies on a 5-point Likert scale. We designed survey questions assessing the first level of Kirkpatrick's levels of training evaluation; these questions were reviewed and revised by the department's Medical Education Scholarship Committee for validity.
A mean of 18 residents attended each session. Seventy-six percent of residents (26 of 34) completed the precurriculum survey, 67% (23 of 34) completed the postcurriculum survey, and 44% (15 of 34) completed both. For all respondents, mean reported confidence with curriculum topics increased from 3.5 to 4.0 (
< .05). For residents completing both surveys, confidence increased from 3.4 to 4.0 (
< .01).
Application of this curriculum significantly improved learner confidence in targeted OB/GYN topics. Future directions could include evaluating curricular impact at higher levels in the Kirkpatrick model, extending sessions to include more time for interaction, and adding suggested readings.
In sexual assault cases, little research has examined differences in forensic medical findings and law enforcement response by victim age across the entire age range.
This study addressed this gap by ...comparing four victim age groups: adults, adolescents over the age of consent, adolescents under the age of consent, and children under 12.
Cases were randomly sampled from a statewide database of medical reports on sexual assault examinations conducted in hospital emergency departments, including only cases reported to law enforcement (N = 563).
Data were combined from a medical report database, from coding of medical documentation and crime laboratory reports, and from case data provided by law enforcement.
Rates for both younger and older adolescent victims and adult victims were comparable, with no statistically significant differences on most variables: penetration, perpetrator use of force, non-genital and genital injuries, presence of biological evidence, generating assailant DNA profiles, DNA match to suspect, hits in the FBI’s DNA database, and law enforcement unfounding (i.e., determining allegations to be false or baseless). Child victims were significantly less likely to have a non-genital injury, and their cases were significantly more likely to be founded by law enforcement. Arrests were significantly more likely when victims were under the age of consent.
Despite significant differences by victim age, similarity between adolescent and adult cases was substantial. Both younger and older adolescents may be at higher risk of physical violence during sexual assault than previously recognized, and need greater attention in response systems.
AudienceThe Residents-as-Teachers (RAT) curriculum is designed for emergency medicine (EM) residents of all years (PGY1-4). Length of CurriculumThe curriculum is divided into three hour-long ...sessions. The entire curriculum can be run as a single block or can be spread out over multiple days. IntroductionThe Accreditation Council of Graduate Medical Education (ACGME) and the Liaison Committee on Medical Education (LCME) both require residents to receive training in teaching medical students and junior residents. They also require opportunities for residents to participate in teaching and be assessed on their effectiveness in this role.1,2 However, the ACGME does not provide guidance or require formal curricula on molding residents into effective teachers. Many programs and institutions have incorporated RAT curricula as a solution to provide residents with the skills necessary to create an excellent educational environment for junior learners. These curricula have been embraced by many specialties, including Emergency Medicine (EM).3-6 The effectiveness of the teaching received during the clinical rotations has important long-term effects on medical students, and may impact their future career choices in medicine.6The COVID-19 pandemic has also required education institutions to vastly alter the delivery of their didactics, including moving to a virtual platform. A completely online format has many benefits that extend beyond the pandemic, such as easier access to participants (including those off-service or at remote sites), no requirement for a physical space, and easier recording of sessions. Educational GoalsTo provide residents with an introduction to teaching techniques that can be utilized on-shift to facilitate an excellent educational experience for junior learners while balancing the resident's patient care responsibilities. Educational MethodsThe educational strategies used in this curriculum include PowerPoint (Redmond, WA) slideshows given by a live presenter via the telecommunications platform Zoom (San Jose, CA), viewing of videos demonstrating curriculum topics, simulation-based learning through role-play, and small-group discussions including simulation debriefing. Research MethodsA survey was distributed to residents before and following the completion of the three training sessions to assess resident satisfaction with the delivery of the content and comfort with the teaching tools discussed. Suggestions on potential improvements were also assessed to inform changes to future iterations of the curriculum. Comfort regarding the included teaching tools was assessed using a five-point Likert scale. After completion of the curriculum, rotating medical students were provided with an evaluation form to assess if residents were teaching using the techniques from the course. ResultsBoth the pre-curriculum and post-curriculum surveys had a response rate of 61.1%. Student's t-test showed a statistically significant increase in mean resident comfort level with the teaching strategies post-curriculum (3.05 to 3.83, p < 0.01). Medical student evaluations have shown, overall, that the majority of residents are utilizing the education techniques on-shift. There were no significant differences found in medical student perception of resident use of taught skills between those who had and had not attended the sessions. However, all but one assessed skill showed higher utilization in those who had attended the correlating session. DiscussionThe educational content was effective in improving the residents' comfort with the teaching strategies presented, and residents are utilizing these techniques on-shift. Through implementation, we discovered that presenting a curriculum over video conferencing required additional administrative support to help ensure efficacy of break-out groups. Based on resident feedback after the first session, multiple changes were made, including providing residents with hand-out references for use during the role-playing sessions. The success of this curriculum demonstrated the feasibility and utility of running a RAT curriculum entirely in a virtual format. TopicsResidents-as-teachers, distance learning, role-playing, virtual curriculum, video conferencing, One Minute Preceptor, feedback, "What if?" game, Aunt Minnie, SPIT, activated demonstration, self-directed teaching tools, teaching scripts, Post-It Pearls.
The aim of this study was to understand prosecutors' perspectives on the contribution of Sexual Assault Nurse Examiners (SANEs) to evidence collection and trials in sexual assault cases.
Several ...studies have suggested that a sexual assault case is more likely to progress in the criminal justice system when a SANE conducts the forensic medical examination. However, little is known about how prosecutors perceive SANEs and what they value about SANEs versus other medical professionals.
Semistructured interviews, conducted in one jurisdiction with eight assistant district attorneys who prosecute sexual assault cases, included questions about the value of SANEs in evidence collection and trials. Interview transcripts were analyzed to identify common themes and variability among prosecutors.
Most prosecutors identified advantages for SANEs in evidence collection, trial preparation, and testimony. Specific advantages cited by one or more prosecutors included superior documentation, thoroughness of the physical examination, better identification of injuries, quality of relationships with patients, professionalism, skill in trial preparation and testifying, and credibility with jurors.
These findings help validate SANEs' contribution to the criminal justice response to sexual assault, despite the study's limitations in sample size and inclusion of only one jurisdiction. The study also suggests the value of further education about SANEs for prosecutors who may not have the opportunity to learn about the range of skills SANEs possess.
The Residents-as-Teachers (RAT) curriculum is designed for emergency medicine (EM) residents of all years (PGY1-4).
The curriculum is divided into three hour-long sessions. The entire curriculum can ...be run as a single block or can be spread out over multiple days.
The Accreditation Council of Graduate Medical Education (ACGME) and the Liaison Committee on Medical Education (LCME) both require residents to receive training in teaching medical students and junior residents. They also require opportunities for residents to participate in teaching and be assessed on their effectiveness in this role.1,2 However, the ACGME does not provide guidance or require formal curricula on molding residents into effective teachers. Many programs and institutions have incorporated RAT curricula as a solution to provide residents with the skills necessary to create an excellent educational environment for junior learners. These curricula have been embraced by many specialties, including Emergency Medicine (EM).3-6 The effectiveness of the teaching received during the clinical rotations has important long-term effects on medical students, and may impact their future career choices in medicine.6The COVID-19 pandemic has also required education institutions to vastly alter the delivery of their didactics, including moving to a virtual platform. A completely online format has many benefits that extend beyond the pandemic, such as easier access to participants (including those off-service or at remote sites), no requirement for a physical space, and easier recording of sessions.
To provide residents with an introduction to teaching techniques that can be utilized on-shift to facilitate an excellent educational experience for junior learners while balancing the resident's patient care responsibilities.
The educational strategies used in this curriculum include PowerPoint (Redmond, WA) slideshows given by a live presenter via the telecommunications platform Zoom (San Jose, CA), viewing of videos demonstrating curriculum topics, simulation-based learning through role-play, and small-group discussions including simulation debriefing.
A survey was distributed to residents before and following the completion of the three training sessions to assess resident satisfaction with the delivery of the content and comfort with the teaching tools discussed. Suggestions on potential improvements were also assessed to inform changes to future iterations of the curriculum. Comfort regarding the included teaching tools was assessed using a five-point Likert scale. After completion of the curriculum, rotating medical students were provided with an evaluation form to assess if residents were teaching using the techniques from the course.
Both the pre-curriculum and post-curriculum surveys had a response rate of 61.1%. Student's t-test showed a statistically significant increase in mean resident comfort level with the teaching strategies post-curriculum (3.05 to 3.83, p < 0.01). Medical student evaluations have shown, overall, that the majority of residents are utilizing the education techniques on-shift. There were no significant differences found in medical student perception of resident use of taught skills between those who had and had not attended the sessions. However, all but one assessed skill showed higher utilization in those who had attended the correlating session.
The educational content was effective in improving the residents' comfort with the teaching strategies presented, and residents are utilizing these techniques on-shift. Through implementation, we discovered that presenting a curriculum over video conferencing required additional administrative support to help ensure efficacy of break-out groups. Based on resident feedback after the first session, multiple changes were made, including providing residents with hand-out references for use during the role-playing sessions. The success of this curriculum demonstrated the feasibility and utility of running a RAT curriculum entirely in a virtual format.
Residents-as-teachers, distance learning, role-playing, virtual curriculum, video conferencing, One Minute Preceptor, feedback, "What if?" game, Aunt Minnie, SPIT, activated demonstration, self-directed teaching tools, teaching scripts, Post-It Pearls.
Furan, a possible human carcinogen, is found in heat treated foods and tobacco smoke. Previous studies have shown that humans are capable of converting furan to its reactive metabolite, ...cis-2-butene-1,4-dial (BDA), and therefore may be susceptible to furan toxicity. Human risk assessment of furan exposure has been stymied because of the lack of mechanism-based exposure biomarkers. Therefore, a sensitive LC-MS/MS assay for six furan metabolites was applied to measure their levels in urine from furan-exposed rodents as well as in human urine from smokers and nonsmokers. The metabolites that result from direct reaction of BDA with lysine (BDA-N α-acetyllysine) and from cysteine-BDA-lysine cross-links (N-acetylcysteine-BDA-lysine, N-acetylcysteine-BDA-N α-acetyllysine, and their sulfoxides) were targeted in this study. Five of the six metabolites were identified in urine from rodents treated with furan by gavage. BDA-N α-acetyllysine, N-acetylcysteine-BDA-lysine, and its sulfoxide were detected in most human urine samples from three different groups. The levels of N-acetylcysteine-BDA-lysine sulfoxide were more than 10 times higher than that of the corresponding sulfide in many samples. The amount of this metabolite was higher in smokers relative to that in nonsmokers and was significantly reduced following smoking cessation. Our results indicate a strong relationship between BDA-derived metabolites and smoking. Future studies will determine if levels of these biomarkers are associated with adverse health effects in humans.
IMPORTANCE: Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. OBJECTIVE: To assess ...whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of 1232 adults aged 60 years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitment was from January 2015 to May 2018, with follow-up until July 2018. INTERVENTIONS: Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). MAIN OUTCOMES AND MEASURES: The primary outcome was incident delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death. RESULTS: Of the 1232 randomized patients (median age, 69 years range, 60 to 95; 563 women 45.7%), 1213 (98.5%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604 patients (26.0%) in the guided group and 140 of 609 patients (23.0%) in the usual care group (difference, 3.0% 95% CI, −2.0% to 8.0%; P = .22). Median end-tidal volatile anesthetic concentration was significantly lower in the guided group than the usual care group (0.69 vs 0.80 minimum alveolar concentration; difference, −0.11 95% CI, −0.13 to −0.10), and median cumulative time with EEG suppression was significantly less (7 vs 13 minutes; difference, −6.0 95% CI, −9.9 to −2.1). There was no significant difference between groups in the median cumulative time with mean arterial pressure below 60 mm Hg (7 vs 7 minutes; difference, 0.0 95% CI, −1.7 to 1.7). Undesirable movement occurred in 137 patients (22.3%) in the guided and 95 (15.4%) in the usual care group. No patients reported intraoperative awareness. Postoperative nausea and vomiting was reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse events were reported in 124 patients (20.2%) in the guided and 130 (21.0%) in the usual care group. Within 30 days of surgery, 4 patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died. CONCLUSIONS AND RELEVANCE: Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02241655
BACKGROUND:Postoperative delirium is a common complication that hinders recovery after surgery. Intraoperative electroencephalogram suppression has been linked to postoperative delirium, but it is ...unknown if this relationship is causal or if electroencephalogram suppression is merely a marker of underlying cognitive abnormalities. The hypothesis of this study was that intraoperative electroencephalogram suppression mediates a nonzero portion of the effect between preoperative abnormal cognition and postoperative delirium.
METHODS:This is a prespecified secondary analysis of the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized trial, which enrolled patients age 60 yr or older undergoing surgery with general anesthesia at a single academic medical center between January 2015 and May 2018. Patients were randomized to electroencephalogram-guided anesthesia or usual care. Preoperative abnormal cognition was defined as a composite of previous delirium, Short Blessed Test cognitive score greater than 4 points, or Eight Item Interview to Differentiate Aging and Dementia score greater than 1 point. Duration of intraoperative electroencephalogram suppression was defined as number of minutes with suppression ratio greater than 1%. Postoperative delirium was detected via Confusion Assessment Method or chart review on postoperative days 1 to 5.
RESULTS:Among 1,113 patients, 430 patients showed evidence of preoperative abnormal cognition. These patients had an increased incidence of postoperative delirium (151 of 430 35% vs.123 of 683 18%, P < 0.001). Of this 17.2% total effect size (99.5% CI, 9.3 to 25.1%), an absolute 2.4% (99.5% CI, 0.6 to 4.8%) was an indirect effect mediated by electroencephalogram suppression, while an absolute 14.8% (99.5% CI, 7.2 to 22.5%) was a direct effect of preoperative abnormal cognition. Randomization to electroencephalogram-guided anesthesia did not change the mediated effect size (P = 0.078 for moderation).
CONCLUSIONS:A small portion of the total effect of preoperative abnormal cognition on postoperative delirium was mediated by electroencephalogram suppression. Study precision was too low to determine if the intervention changed the mediated effect.
Intraoperative EEG suppression duration has been associated with postoperative delirium and mortality. In a clinical trial testing anaesthesia titration to avoid EEG suppression, the intervention did ...not decrease the incidence of postoperative delirium, but was associated with reduced 30-day mortality. The present study evaluated whether the EEG-guided anaesthesia intervention was also associated with reduced 1-yr mortality.
This manuscript reports 1 yr follow-up of subjects from a single-centre RCT, including a post hoc secondary outcome (1-yr mortality) in addition to pre-specified secondary outcomes. The trial included subjects aged 60 yr or older undergoing surgery with general anaesthesia between January 2015 and May 2018. Patients were randomised to receive EEG-guided anaesthesia or usual care. The previously reported primary outcome was postoperative delirium. The outcome of the current study was all-cause 1-yr mortality.
Of the 1232 subjects enrolled, 614 subjects were randomised to EEG-guided anaesthesia and 618 subjects to usual care. One-year mortality was 57/591 (9.6%) in the guided group and 62/601 (10.3%) in the usual-care group. No significant difference in mortality was observed (adjusted absolute risk difference, –0.7%; 99.5% confidence interval, –5.8% to 4.3%; P=0.68).
An EEG-guided anaesthesia intervention aiming to decrease duration of EEG suppression during surgery did not significantly decrease 1-yr mortality. These findings, in the context of other studies, do not provide supportive evidence for EEG-guided anaesthesia to prevent intermediate term postoperative death.
NCT02241655.
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