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AbstractDietary supplement use is common in the United States. Supplements are regulated by the US Food and Drug Administration (FDA) under a separate set of guidelines from typical food and drug products. This case report describes a patient who presented to the emergency department (ED) with abdominal pain, vomiting, and generalized weakness. On detailed history, we learned that he had been taking a supplement called Artri Ajo King for 18 months, followed by recent abrupt cessation before his ED presentation. He was subsequently found to have a low serum cortisol level and was diagnosed with secondary adrenal insufficiency by a cosyntropin stimulation test. Ultimately, he was started on hydrocortisone with resolution of his symptoms. This case illustrates the consequence of allowing dietary supplements to be sold before FDA evaluation as well as the importance of physicians eliciting history of supplement use and offering a culturally competent discussion with their patients regarding supplement use.

Introduction: Optimizing the performance of emergency department (ED) teams impacts patient care, but the utility of current, team-based performance assessment tools to comprehensively measure this impact is underexplored. In this study we aimed to 1) evaluate ED team performance using current team-based assessment tools during an interprofessional in situ simulation and 2) identify characteristics of effective ED teams. Methods: This mixed-methods study employed case study methodology based on a constructivist paradigm. Sixty-three eligible nurses, technicians, pharmacists, and postgraduate year 2–4 emergency medicine residents at a tertiary academic ED participated in a 10-minute in situ simulation of a critically ill patient. Participants self-rated performance using the Team Performance Observation Tool (TPOT) 2.0 and completed a brief demographic form. Two raters independently reviewed simulation videos and rated performance using the TPOT 2.0, Team Emergency Assessment Measure (TEAM), and Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS). Following simulations, we conducted semi-structured interviews and focus groups with in situ participants. Transcripts were analyzed using thematic analysis. Results: Eighteen team-based simulations took place between January–April 2021. Raters’ scores were on the upper end of the tools for the TPOT 2.0 (R1 4.90, SD 0.17; R2 4.53, SD 0.27, IRR [inter-rater reliability] 0.47), TEAM (R1 3.89, SD 0.19; R2 3.58, SD 0.39, IRR 0.73), and Ottawa GRS (R1 6.6, SD 0.56; R2 6.2, SD 0.54, IRR 0.68). We identified six themes from our interview data: team member entrustment; interdependent energy; leadership tone; optimal communication; strategic staffing; and simulation empowering team performance. Conclusion: Current team performance assessment tools insufficiently discriminate among high performing teams in the ED. Emergency department-specific assessments that capture features of entrustability, interdependent energy, and leadership tone may offer a more comprehensive way to assess an individual’s contribution to a team’s performance.

Ebstein’s anomaly is a congenital heart defect that when left untreated can lead to unique physical exam and ultrasound findings. This case describes a patient who presented with dyspnea and was found to have cyanosis, clubbing, and dilation of right-sided chambers on point-of-care ultrasound. The series of images highlights findings in late-stage Ebstein’s anomaly and serves as a springboard for the discussion of the pathophysiology, diagnosis, and treatment of this rare congenital heart disease.

AbstractEmergency physicians are well‐positioned to take a leadership role in telehealth, particularly in emerging categories such as triage, direct acute unscheduled care, and virtual observation. However, the growth of telehealth has outpaced curricular development in emergency medicine (EM) residency programs. This manuscript presents a model longitudinal telehealth curriculum, developed by the consensus of education experts, including representatives from the telehealth interest groups from EM's two primary specialty societies: the American College of Emergency Physicians and the Society for Academic Emergency Medicine. The curriculum describes overarching goals and components that may serve as a foundation for individual institutions seeking to train future operational and academic leaders in telehealth.

Interprofessional education (IPE) has been shown to improve health outcomes and patient satisfaction. IPE is now represented in the Accreditation Council for Graduate Medical Education’s emergency medicine (EM) milestones given the team-based nature of EM. The Highland Allied Health Rotation Program (H-AHRP) was developed by residents to enhance and standardize IPE for EM residents in a single hospital setting. H-AHRP was incorporated into the orientation month for interns starting in the summer of 2016. EM interns were paired with emergency department preceptors in registered nursing (RN), respiratory therapy (RT), pharmacy (PH), laboratory (LAB), and social work (SW) in either a four-hour shadowing experience (RN, RT, PH) or lecture-based overview (LAB, SW). We conducted a survey before and after the program. Overall, the EM interns reported an improved understanding of the scope of practice and day-to-day logistics after working with the preceptors. They found the program helpful to their future as physicians and would recommend it to other residencies. The H-AHRP program allows for the early incorporation of IPE into EM training, enhances interns’ understanding of both the scope and logistics of their colleagues, and is a well-received effort at improving team-based care.

AbstractObjectivesMedication errors represent a significant threat to patient safety. Pharmacotherapy is one of the 23 Accreditation Council of Graduate Medical Education milestones for emergency medicine, yet there is minimal understanding of what content should be prioritized during training. The study aim was to develop objectives for a patient‐safety focused pharmacology curriculum for emergency medicine residents. MethodsWe incorporated data from a de‐identified safety event database and survey responses of 30 faculty and clinical pharmacists at a single‐site suburban university hospital with 24‐hour emergency medicine pharmacists and an annual volume of approximately 70,000. We reviewed the database to quantify types and severity of medication errors over a 5‐year period for a total of 370 errors. Anonymous surveys included categorical items that we analyzed with descriptive statistics and short answer questions that underwent thematic analysis by 2 coders. We summarized all data sources to identify curriculum gaps. ResultsCommon medication errors reported in our database were wrong dose (43%) and computer order entry errors (14%). Knowledge gaps were medication cost (63%), pregnancy risk information (60%), antibiotic stewardship (53%), interactions (47%), and side effects (47%). Qualitative analysis revealed the need to optimize computer order entry, understand the scope of critical medications, use references, and consult pharmacists. Integration of data suggested specific medications should be covered in curricular efforts, including antibiotics, analgesics, sedatives, and insulin. ConclusionWe developed objectives of pharmacology topics to prioritize during emergency medicine training to enhance prescribing safety. This study is limited due to its small sample and single institution source of data. Future studies should investigate the impact of pharmacology curriculum on minimizing clinical errors.

The goal of this study was to characterize current practices in the transition of care between the emergency department and primary care setting, with an emphasis on the use of the electronic medical record (EMR). Using literature review and modified Delphi technique, we created and tested a pilot survey to evaluate for face and content validity. The final survey was then administered face-to-face at eight different clinical sites across the country. A total of 52 emergency physicians (EP) and 49 primary care physicians (PCP) were surveyed and analyzed. We performed quantitative analysis using chi-square test. Two independent coders performed a qualitative analysis, classifying answers by pre-defined themes (inter-rater reliability > 80%). Participants' answers could cross several pre-defined themes within a given question. EPs were more likely to prefer telephone communication compared with PCPs (30/52 [57.7%] vs. 3/49 [6.1%] P < 0.0001), whereas PCPs were more likely to prefer using the EMR for discharge communication compared with EPs (33/49 [67.4%] vs. 13/52 [25%] p < 0.0001). EPs were more likely to report not needing to communicate with a PCP when a patient had a benign condition (23/52 [44.2%] vs. 2/49 [4.1%] p < 0.0001), but were more likely to communicate if the patient required urgent follow-up prior to discharge from the ED (33/52 [63.5%] vs. 20/49 [40.8%] p = 0.029). When discussing barriers to effective communication, 51/98 (52%) stated communication logistics, followed by 49/98 (50%) who reported setting/environmental constraints and 32/98 (32%) who stated EMR access was a significant barrier. Significant differences exist between EPs and PCPs in the transition of care process. EPs preferred telephone contact synchronous to the encounter whereas PCPs preferred using the EMR asynchronous to the encounter. Providers believe EP-to-PCP contact is important for improving patient care, but report varied expectations and multiple barriers to effective communication. This study highlights the need to optimize technology for an effective transition of care from the ED to the outpatient setting.

During the COVID-19 pandemic, educational systems worldwide faced significant disruptions as in-person learning became unfeasible. In response, many institutions, including graduate medical education programs, swiftly transitioned to virtual learning platforms to adapt to these challenges. The rapid and unplanned pivot in learning format resulted in temporary negative impacts on residency training. Conversely, the experience of the rapid shift may have resulted in some long-term benefits while also preparing programs for future disruptions. This review aimed to discuss the advantages and disadvantages of virtual learning, potential mitigation strategies for the realized disadvantages, and potential areas of future research.

Background Despite increased understanding of psoriasis pathogenesis, molecular classification of clinical phenotypes and disease severity is poorly defined. Knowledge gaps include whether molecular endotypes of psoriasis underlie distinct clinical phenotypes and the positive and negative molecular regulators of disease severity across tissue compartments. Methods We performed comprehensive RNA sequencing of skin and blood (n = 718) from prospectively-recruited, deeply-phenotyped discovery and replication cohorts of 146 subjects with moderate-to-severe chronic plaque psoriasis initiating TNF-inhibitor (adalimumab) or IL-12/23-inhibitor (ustekinumab) therapy. Results Here we show, using two complementary dimensionality reduction methods, that co-expressed gene modules and factors within skin and blood are significantly associated with psoriasis phenotypes and disease severity. We identify a 14-gene signature negatively associated with BMI in nonlesional skin and with disease severity in lesional skin. Genotype integration reveals that HLA-DQA1*01 and HLA-DRB1*15 genotypes are positively associated with baseline psoriasis severity. Using explainable machine learning models, we define two disease severity-associated gene modules in lesional skin - one positive, one negatively-associated - and a 9-gene signature in lesional skin predictive of disease severity. Disease severity signatures in blood are only seen following adalimumab exposure, suggesting greater systemic impact of adalimumab compared to ustekinumab, in line with its side effect profile. In contrast, a gene signature in blood linked to HLA-C*06:02 status is independent of disease severity or drug. Conclusions These findings delineate gene-environmental and genetic effects on the psoriasis transcriptome linked to disease severity. Plain language summary Psoriasis is a common and debilitating skin disease, linked to other inflammatory conditions. A lot is known about what causes psoriasis and the factors that influence it, but doctors still cannot offer personalised treatments. This is because it has been difficult to understand what makes psoriasis more or less severe, why people respond differently to treatment, or why some people develop related diseases. To help address this, we collected skin and blood samples and personal information from people with severe psoriasis across the United Kingdom. Using computer-based methods, we found shared biological processes that link the disease with obesity and help predict its severity. Rider, Grantham, Smith, Watson et al. integrate multiomic data from patients with psoriasis using dimensionality reduction and machine learning techniques. This approach identifies biological relationships between genetic background, clinical features and disease severity, providing insight into disease variability across individuals.