Recent Publications by CFE Educators

OBJECTIVES

The standard letter of recommendation (SLOR) is used by most emergency medicine (EM) faculty to submit evaluations for medical students applying for EM residency programs. In the global assessment score (GAS) section, there is a crucial summative question that asks letter writers to estimate the applicant's rank order list (ROL) position in their own program. The primary aim of the study was to determine if these estimated global assessment tiers agreed with the actual ROL, using the criteria recommended by the Council of Emergency Medicine Residency Directors (CORD).

METHODS

Data from SLORs written by EM faculty from five California institutions were retrospectively collected from the 2008-2009 residency application year. Descriptive and comparative statistical analyses were performed using the documented GAS tiers and actual ROL positions.

RESULTS

A total of 105 SLORs were reviewed from the five participating institutions. Three SLORs were excluded and 102 were analyzed. Only 27 (26%) SLORs documented a GAS tier that accurately predicted the applicant's actual ROL position. The GAS tier overestimated the applicant's position on the ROL in 67 (66%) SLORs, whereas it underestimated the position in eight (8%) SLORs. Accuracy was poor regardless of the number of letter writers on the SLOR (p = 0.890), the writer's administrative title (p = 0.326), whether the student was a home or visiting student (p = 0.801), or if the student had prior EM rotation experience (p = 0.793).

CONCLUSIONS

Standard letter of recommendation writers are inaccurate in estimating the ROL position of the applicant using the GAS tier criteria. The GAS tiers were accurate only 26% of the time. Because of the valuable role that the SLOR plays in determining an applicant's competitiveness in the National Resident Matching Program (NRMP) in EM, future discussion should focus on improving the consistency and accuracy of the GAS section. Furthermore, there needs to be a national dialogue to reassess the utility of the criterion-based GAS within the SLOR.

Admission indicators for monitored care in gallstone pancreatitis have been lacking. Recently, we established three criteria for admission to intensive care unit or step down versus ward beds: (1) concomitant cholangitis, (2) heart rate >110 beats/min, and (3) blood urea nitrogen >15 mg/dL. The purpose of this study was to determine whether these criteria would be effective in decreasing monitored care bed utilization without adversely affecting outcomes. A retrospective review of all patients with gallstone pancreatitis at a public teaching hospital was performed (2003-2009). A comparison was made of patients before (2003-2005, Period 1) and after (2006-2009, Period 2) establishment of monitored care triage criteria. Over the study period, there were 379 patients. The median Ranson score for both periods was 1. The median ages were 41 and 39, (P = 0.7). In Period 1, 28 per cent of patients were admitted to the intensive care unit/step down unit versus 12 per cent in Period 2. None of the patients required transfer from the ward to a monitored care setting in Period 2. There were no mortalities in either period. In conclusion, the presence of concomitant cholangitis, heart rate >110, and blood urea nitrogen >15 are useful and safe triage criteria for admission to a monitored care setting. Use of these criteria significantly decreased monitored care bed utilization and resulted in fewer mis-triages without adversely affecting patient outcomes.

OBJECTIVE

Some healthy older adults have difficulty regaining weight after acute weight loss, and the reason for this failure to regain weight is unknown. The objective of this study was to determine if elevated leptin or pro-inflammatory cytokine levels are associated with failure to regain weight over two years after an acute weight loss intervention.

DESIGN

Two year prospective study after an acute weight loss intervention.

SETTING

University of Washington Medical Center from 2001-2006.

PARTICIPANTS

Nineteen older (≥ 70 years old) men and women.

MEASUREMENTS

Body weights, health status questionnaire, body composition data, serum leptin, glucose, insulin, C- reactive protein and pro-inflammatory cytokine levels were measured every six months for two years.

RESULTS

Five subjects out of 19 failed to regain weight after two years. The subjects who failed to regain weight after 2 years had higher circulating levels of tumor necrosis factor receptor particle 55 (TNFRp55) at baseline and at 6, 12, 18 and 24 months of follow up compared to subjects who regained weight after 2 years (P = 0.02 ).

CONCLUSION

Five out of 19 older subjects had difficulty regaining weight for up to 2 years following an acute weight loss intervention, and their TNFRp55 levels were persistently higher than in subjects who regained weight. Greater TNF α action, as reflected by higher circulating levels of TNFRp55, could be contributing towards inability of some older persons to regain weight after acute weight loss.

Having patients, doctors, health plan managers, hospital executives, and other stakeholders participate in the design of comparative effectiveness studies can ensure that this vital research focuses on the evidence gaps most relevant to health care decision makers. Through a qualitative assessment of case studies, we identify five key principles for the effective engagement of a broad coalition of participants in research intended to improve health care and control costs. Those principles are to ensure balance among the participating stakeholders; get participants to "buy in" to the process and understand their roles; provide neutral and expert facilitators for research discussions; establish connections among the participants; and keep the participants engaged throughout the research process.

BACKGROUND

Ventricular free wall rupture is a fatal complication of myocardial infarction (MI). Although described in MI patients who receive thrombolytic therapy, this complication is not well known in ischemic stroke patients who receive intravenous (IV) t-PA.

METHODS

Case report.

RESULTS

We present a 93-year-old woman with an acute onset of a right middle cerebral artery syndrome in the setting of subacute MI. IV t-PA was administered and she subsequently developed asystolic arrest and died. Autopsy showed subacute MI, hemopericardium, and rupture of the left ventricle.

CONCLUSIONS

This case illustrates a fatal cardiac complication of IV thrombolytic therapy for stroke. The speculated mechanism is hemorrhage into the infarcted myocardium.

Physical cues, such as extracellular matrix stiffness, direct cell differentiation and support tissue-specific function. Perturbation of these cues underlies diverse pathologies, including osteoarthritis, cardiovascular disease and cancer. However, the molecular mechanisms that establish tissue-specific material properties and link them to healthy tissue function are unknown. We show that Runx2, a key lineage-specific transcription factor, regulates the material properties of bone matrix through the same transforming growth factor-β (TGFβ)-responsive pathway that controls osteoblast differentiation. Deregulated TGFβ or Runx2 function compromises the distinctly hard cochlear bone matrix and causes hearing loss, as seen in human cleidocranial dysplasia. In Runx2+/⁻ mice, inhibition of TGFβ signalling rescues both the material properties of the defective matrix, and hearing. This study elucidates the unknown cause of hearing loss in cleidocranial dysplasia, and demonstrates that a molecular pathway controlling cell differentiation also defines material properties of extracellular matrix. Furthermore, our results suggest that the careful regulation of these properties is essential for healthy tissue function.

Although the formalin test is a widely used model of persistent pain, the primary afferent fiber types that underlie the cellular and behavioral responses to formalin injection are largely unknown. Here we used a combined genetic and pharmacological approach to investigate the effect of ablating subsets of primary afferent nociceptors on formalin-induced nocifensive behaviors and spinal cord Fos protein expression. Intrathecal capsaicin-induced ablation of the central terminals of TRPV1+neurons greatly reduced the behavioral responses and Fos elicited by low-dose (0.5%) formalin. In contrast, genetic ablation of the MrgprD-expressing subset of non-peptidergic unmyelinated afferents, which constitute a largely non-overlapping population, altered neither the behavior nor the Fos induced by low-dose formalin. Remarkably, nocifensive behavior following high-dose (2%) formalin was unchanged in mice lacking either afferent population, or even in mice lacking both populations, which together make up the great majority of C-fiber nociceptors. Thus, at high doses, which are routinely used in the formalin test, formalin-induced "pain" behavior persists in the absence of the vast majority of C-fiber nociceptors, which points to a contribution of a large spectrum of afferents secondary to non-specific formalin-induced tissue and nerve damage.