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Patients with chronic kidney disease (CKD)/end stage renal disease (ESRD) can experience several severe complications, including acute coronary syndrome (ACS). While troponin is the biomarker of choice for evaluation of ACS, interpretation of troponin in CKD/ESRD can be challenging. This narrative review evaluates troponin elevation in patients with CKD/ESRD, pitfalls in the evaluation with troponin, and an approach to using troponin in these high-risk patients. Patients with CKD/ESRD are at greater risk for ACS and possess higher levels of circulating troponin. Relatedly, these patients often present atypically for ACS. Several pitfalls must be considered in the use of troponin when evaluating for ACS. While troponin elevation in patients with CKD/ESRD is often considered to be due to underlying renal disease, this elevation has several etiologies including uremic skeletal myopathy, microinfarctions, left ventricular hypertrophy (LVH), decreased clearance, and unrecognized congestive heart failure (CHF). Utilizing troponin assays in this patient population requires a nuanced approach, as the sensitivity and specificity for troponin testing in CKD varies. Concern for ACS with elevated troponin warrants treatment for ACS until proven otherwise, with consideration of atypical presentations along with other causes for patient symptoms that may result in troponin elevation. Patients with CKD/ESRD presenting with symptoms concerning for ACS are challenging. The utilization of troponin assays is important in this population given their high risk of ACS but requires an educated and nuanced approach.

Introduction: We discuss a case of massive hemoptysis in the setting of a direct-acting oral anticoagulant (DOAC) successfully managed with nebulized tranexamic acid (TXA). Case Report: Per the American College of Cardiology and the American Society of Hematology, it is recommended that significant bleeding associated with a DOAC be treated with either 4-factor prothrombin complex concentrate or andexanet alfa. However, our patient was at high risk for thrombotic complications given a recent pulmonary embolism. Conclusion: We demonstrate that it is reasonable to trial nebulized TXA given its low cost, ease of administration, and safety profile. Additionally, this report discusses a unique dosing strategy and a previously unreported complication associated with nebulization of undiluted TXA.

In 2017, all medical students applying for residency in emergency medicine (EM) were required to participate in the Standardized Video Interview (SVI). The SVI is a video-recorded, uni-directional interview consisting of six questions designed to assess interpersonal and communication skills and professionalism. It is unclear whether this simulated interview is an accurate representation of an applicant's competencies that are often evaluated during the in-person interview. The goal of this study was to determine whether the SVI score correlates with a traditional in-person interview score. Six geographically and demographically diverse EM residency programs accredited by the Accreditation Council for Graduate Medical Education participated in this prospective observational study. Common demographic data for each applicant were obtained through an Electronic Residency Application Service export function prior to the start of any scheduled traditional interviews (TI). On each TI day, one interviewer blinded to all applicant data, including SVI score, rated the applicant on a five-point scale. A convenience sample of applicants was enrolled based on random assignment to the blinded interviewer. We studied the correlation between SVI score and TI score. We included 321 unique applicants in the final analysis. Linear regression analysis of the SVI score against the TI score demonstrated a small positive linear correlation with an r coefficient of +0.13 (p=0.02). This correlation remained across all SVI score subgroups (p = 0.03). Our study suggests that there is a small positive linear correlation between the SVI score and performance during the TI.

In 2017, the Standardized Video Interview (SVI) was required for applicants to emergency medicine (EM). The SVI contains six questions highlighting professionalism and interpersonal communication skills. The responses were scored (6-30). As it is a new metric, no information is available on correlation between SVI scores and other application data. This study was to determine if a correlation exists between applicants' United States Medical Licensing Examination (USMLE) and SVI scores. We hypothesized that numeric USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores would not correlate with the SVI score, but that performance on the Step 2 Clinical Skills (CS) portion may correlate with the SVI since both test communication skills. Nine EM residency sites participated in the study with data exported from an Electronic Residency Application Service (ERAS®) report. All applicants with both SVI and USMLE scores were included. We studied the correlation between SVI scores and USMLE scores. Predetermined subgroup analysis was performed based on applicants' USMLE Step 1 and Step 2 CK scores as follows: (≥ 200, 201-220, 221-240, 241-260, >260). We used linear regression, the Kruskal-Wallis test and Mann-Whitney U test for statistical analyses. 1,325 applicants had both Step 1 and SVI scores available, with no correlation between the overall scores (p=0.58) and no correlation between the scores across all Step 1 score ranges, (p=0.29). Both Step 2 CK and SVI scores were available for 1,275 applicants, with no correlation between the overall scores (p=0.56) and no correlation across all ranges, (p=0.10). The USMLE Step 2 CS and SVI scores were available for 1,000 applicants. Four applicants failed the CS test without any correlation to the SVI score (p=0.08). We found no correlation between the scores on any portion of the USMLE and the SVI; therefore, the SVI provides new information to application screeners.

Learning Objectives: To design an anatomically accurate, reusable model of resuscitative hysterotomy providing learners realistic practice without utilizing biological tissue. Secondary objectives included minimizing utilization costs, while developing procedural proficiency for large groups of trainees.Introduction/Background: High-acuity and low-frequency procedures are an important component of emergency medicine training that not all residents encounter before graduation. The pregnant patient in cardiac arrest requiring resuscitative hysterotomy exemplifies this phenomenon. High-fidelity commercial models are expensive, thus less suitable for repeated use by inexperienced learners. Conversely, many low cost models lack anatomic fidelity required to replicate the procedure. We present a low cost, high-fidelity option that is non-tissue based and conducive to repeated use. This allows learners to practice the technique prior to performing an invasive procedure on a patient.Curricular Design: Gaumard S500 Original Childbirth Simulator, a childbirth skills trainer was repurposed as a rapidly reusable model for resuscitative hysterotomy. The empty pelvic base was fitted with a plastic sac containing a baby in simulated amniotic fluid and adjacent placenta. Pelvic organs including a bladder, uterus, subcutaneous tissue and skin were designed using soft pourable silicone rubber. Layers were colored to match soft tissue texture and appearance prior to assembly within the pelvic base. As learners successively perform the procedure, the abdominal covering and uterus layers can be easily resealed for repeated incisions.Impact/Effectiveness: A cost-effective and reusable model allows residents to practice high-acuity, low-frequency procedures in realistic patient care scenarios. This model was implemented with 40 GME and UME learners performing the procedure during a simulated case during weekly didactics. Each participant described the experience as realistic and effective in improving confidence. The model will be integrated annually into simulation activities with plans to expand to other healthcare professionals via in-situ simulation scenarios in the ED.

Videoconferencing has been employed in numerous medical education settings ranging from remote supervision of medical trainees to conducting residency interviews. However, no studies have yet documented the utility of and student response to videoconference meetings for mid-clerkship feedback (MCF) sessions required by the Liaison Committee on Medical Education (LCME). From March 2017 to June 2018, third-year medical students rotating through the mandatory, four-week emergency medicine (EM) clerkship at a single medical school were randomly assigned either to a web-based videoconference meeting via Google Hangouts, or to a traditional in-person meeting for their MCF session. To compare students' MCF experiences we sent out an electronic survey afterward to assess the following using a 0-100 sliding scale: overall satisfaction with the meeting; the effectiveness of communication; the helpfulness of the meeting; their stress levels, and the convenience of their meeting location. The survey also collected data on these demographic variables: the name of the faculty member with whom the student met; student gender, age, and interest in EM; location prior to meeting; meeting-method preference; and number of EM shifts completed. During the study period, 133 third-year medical students responded to the survey. When comparing survey responses between individuals who met online and in person, we did not detect a difference in demographics with the exception of preferred meeting method (p=0.0225). We found no significant differences in the overall experience, helpfulness of the meeting, or stress levels of the meeting between those who met via videoconference vs. in-person (p=0.9909; p=0.8420; p=0.2352, respectively). However, individuals who met in-person with a faculty member rated effectiveness of communication higher than those who met via videoconference (p=0.0002), while those who met online rated convenience higher than those who met in-person (p<0.0001). Both effects remained significant after controlling for preferred meeting method (p<0.0001 and p=0.0003, respectively) and among EM-bound students (p=.0423 and p<0.0110, respectively). Our results suggest that LCME-required MCF sessions can be successfully conducted via web-based programs such as Google Hangouts without jeopardizing overall meeting experience. While the convenience of the meetings was improved, it is also important for clerkship directors to note the perceived deficit in the effectiveness of communication with videoconferencing.

Introduction:In 2017, all medical students applying for residency in emergency medicine (EM) were required to participate in the Standardized Video Interview (SVI). The SVI is a video-recorded, uni-directional interview consisting of six questions designed to assess interpersonal and communication skills and professionalism. It is unclear whether this simulated interview is an accurate representation of an applicant’s competencies that are often evaluated during the in-person interview. Objective: The goal of this study was to determine whether the SVI score correlates with a traditional in-person interview score.Methods:Six geographically and demographically diverse EM residency programs accredited by the Accreditation Council for Graduate Medical Education participated in this prospective observational study. Common demographic data for each applicant were obtained through an Electronic Residency Application Service export function prior to the start of any scheduled traditional interviews (TI). On each TI day, one interviewer blinded to all applicant data, including SVI score, rated the applicant on a five-point scale. A convenience sample of applicants was enrolled based on random assignment to the blinded interviewer. We studied the correlation between SVI score and TI score.Results:We included 321 unique applicants in the final analysis. Linear regression analysis of the SVI score against the TI score demonstrated a small positive linear correlation with an r coefficient of +0.13 (p=0.02). This correlation remained across all SVI score subgroups (p = 0.03).Conclusion: Our study suggests that there is a small positive linear correlation between the SVI score and performance during the TI.

Although there is ample evidence that smoking increases the risk of tuberculosis (TB), the magnitude of impact on TB risk among HIV-infected persons is poorly described. Given that a high proportion of patients with TB are co-infected with HIV in South Africa, the risks arising from the intersection of smoking, TB, and HIV/AIDS have key relevance for tobacco control policies. To evaluate the association of pulmonary tuberculosis (PTB) with current tobacco smoking among men with HIV in South Africa. Case-control study of antiretroviral therapy naïve men with confirmed HIV-infection in Johannesburg. Cases had laboratory-confirmed PTB and controls had no evidence of active TB. Participants were interviewed to collect detailed smoking histories. We enrolled 146 men diagnosed with PTB and 133 controls. Overall, 33% of participants were currently smoking, defined as smoking a cigarette within 2 months (34% cases vs. 32% controls, p = 0.27). Median CD4 count was lower (60 vs. 81 cells/mm3, P = 0.03) and median viral load was higher (173 vs. 67 copies/ul per thousand, P<0.001) among cases versus controls. In adjusted analyses, current smoking tripled the odds of PTB (aOR 3.2; 95%CI: 1.3-7.9, P = 0.01) and former smoking nearly doubled the odds of PTB (aOR 1.8; 95%CI 0.8-4.4, P = 0.18) compared to never smoking. Males with HIV that smoke are at greater odds for developing PTB than non-smokers. Extensive smoking cessation programs are needed to reduce odds of TB and promote health among adults living with HIV.

Aster-like nanoparticles (ALNs) are femtoentities, recently discovered in different aquatic environments, whose intrinsic nature and ecological features remain to be determined. In this study, we investigate the in situ temporal dynamics of ALNs during 1 year in 3 different lakes, in relation to the physico-chemical and biological environment. ALN abundances in investigated lakes showed a marked seasonal dynamic (from no detectable to 4.28 ± 0.75 × 10 6 ALNs mL −1 ), with characteristic peaks in spring. We recorded a correlation between ALNs and some prokaryotic phyla suggesting a broad and non-specific relationship. From their seasonal dynamics and potential link with prokaryotes, we conclude that ALNs represent an important ecological actor in the functioning of aquatic ecosystems.