Can USMLE and COMLEX-USA Scores Predict At-Risk Emergency Medicine Residents' Performance on In-Training Examinations?

PURPOSE: The United States Medical Licensing Examination (USMLE) and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) scores are standard methods used to determine residency candidates' medical knowledge. The authors were interested in using the USMLE and COMLEX part 2 scores in our emergency medicine (EM) residency program to identify at-risk residents who may have difficulty on the in-training exam (ITE) and to determine the cutoff values under which an intern could be given an individualized study plan to ensure medical knowledge competency. METHODS: The authors abstracted the USMLE and COMLEX part 2 scores and the American Board of Emergency Medicine (ABEM) ITE scores for a cohort of first-year EM residents graduating years 2010-2022, converting raw scores to percentiles, and compared part 2 and ABEM ITE scores with Pearson's correlation, a Bland-Altman analysis of bias and 95% limits of agreement, and ROC analysis to determine optimal the cut-off values for predicting ABEM ITE < 50th percentile and the estimated test characteristics. RESULTS: Scores were available for 152 residents, including 93 USMLE and 88 COMLEX exams. The correlations between part 2 scores and ABEM ITE were r = 0.36 (95%CI: 0.17, 0.52; p < 0.001) for USMLE and r = 0.50 (95%CI: 0.33, 0.64; p < 0.001) for COMLEX. Bias and limits of agreement for both part 2 scores were -14 ± 63% for USMLE and 13 ± 50% for COMLEX in predicting the ABEM ITE scores. USMLE < 37th percentile and COMLEX < 53rd percentile identified 42% (N = 39) and 27% (N = 24) of EM residents, respectively, as at risk, with a sensitivity of 61% and 49% and specificity of 71% and 92%, respectively. CONCLUSION: USMLE and COMLEX part 2 scores have a very limited role in identifying those at risk of low ITE performance, suggesting that other factors should be considered to identify interns in need of medical knowledge remediation.

Decision Support to Improve Critical Care Services Documentation in an Academic Emergency Department.

OBJECTIVES: Critical care services (CCS) documentation affects billing, operations, and research. No studies exist on documentation decision support (DDS) for CCS in the emergency department (ED). We describe the design, implementation, and evaluation of a DDS tool built to improve CCS documentation at an academic ED. METHODS: This quality improvement study reports the prospective design, implementation, and evaluation of a novel DDS tool for CCS documentation at an academic ED. CCS-associated ED diagnoses triggered a message to appear within the physician note attestation workflow for any patient seen in the adult ED. The alert raised awareness of CCS-associated diagnoses without recommending specific documentation practices. The message disappeared from the note automatically once signed. We measured current procedural terminology (CPT) codes 99291 or 99292 (representing CCS rendered) for 8 months before and after deployment to identify CCS documentation rates. We performed state-space Bayesian time-series analysis to evaluate the causal effect of our intervention on CCS documentation capture. We used monthly ED volume and monthly admission rates as covariate time-series for model generation. RESULTS: The study included 92,350 ED patients with an observed mean proportion CCS of 3.9% before the intervention and 5.8% afterward. The counterfactual model predicted an average response of 3.9% [95% CI 3.5-4.3%]. The estimated absolute causal effect of the intervention was 2.0% [95% CI 1.5-2.4%] (p = 0.001). CONCLUSION: A DDS tool measurably increased ED CCS documentation. Attention to user workflows and collaboration with compliance and billing teams avoided alert fatigue and ensures compliance.

Coordinating ecological risk assessment with natural resource damage assessment: A panel discussion.

Contaminated sites in the United States undergo remediation and restoration through regulatory programs that lead the 2 processes through independent but often parallel pathways with different objectives. The objective of remediation is to reduce risk to human health and the environment, whereas that of restoration is to restore injured resources and compensate the public for lost use of the services that natural resources provide. More complex sites, such as those associated with large river systems and urban waterways, have resulted in increasingly larger-scale ecological risk assessments (ERAs) and natural resource damage assessments (NRDAs) that take many years and involve diverse practitioners including scientists, economists, and engineers. Substantial levels of effort are now frequently required, creating a need for more efficient and cost-effective approaches to data collection, analyses, and assessments. Because there are commonalities in the data needs between ERAs and NRDAs, coordination of the design and implementation of site-specific studies that meet the needs of both programs could result in increased efficiency and lower costs. The Association for Environmental Health and Sciences Foundation convened a panel of environmental practitioners from industry, consulting, and regulatory bodies to examine the benefits and challenges associated with coordinating ERA and NRDA activities in the context of a broad range of regulatory programs. This brief communication presents the opinions and conclusions of the panelists on these issues and reports 2 case studies for which coordinated ERA and NRDA activities produced a positive outcome. Integr Environ Assess Manag 2016;12:616-621. © 2015 SETAC.

A fluorescent chemosensor for calcium with excellent storage stability in water.

This article describes the design, synthesis and characterization of an optical sensor suitable for practical measurement of ionized calcium in serum and whole blood samples. The key to the development of this sensor is the identification of a chemically very stable, nitrogen-containing, calcium selective ionophore, coupled with a fluorophore having the correct spectral and electron accepting properties. The slope of the sensor is about 34%/mM in the typical clinically significant range of 0.32-2.2mM. This sensor has been implemented into the disposable cartridge, used for commercially available OPTI CCA analyzer with precision better than +/-0.02 mM (1S.D.). The sensor displays excellent stability against hydrolysis and oxidation, leading to less than 0.02 mM measurement error after 9 months of wet storage at room temperature, up to 30 degrees C.

In situ reproduction, abundance, and growth of young-of-year and adult largemouth bass in a population exposed to polychlorinated biphenyls.

We conducted a two-year field study (2000-2001) in the Housatonic River, Massachusetts (USA) to determine if we could detect in situ population-level effects on largemouth bass (Micropterus salmoides) exposed to elevated levels of polychlorinated biphenyls (PCBs). Calculated whole-body PCB concentrations in adult bass in 2002 averaged 121 mg/kg (range = 34-556 mg/kg). Polychlorinated biphenyl concentrations in young-of-year (YOY) composites in 2000 and 2002 averaged 28 mg/kg (range = 21-41 mg/kg) and 19 mg/kg (range = 16-24 mg/kg), respectively. Laboratory studies of fish have reported PCB toxicity at exposure levels below and within the range of those found in the Housatonic River. We evaluated five field-derived metrics: reproductive activity, relative abundance of YOY, YOY growth rates, adult growth, and adult condition to determine whether we could detect effects of PCBs in the largemouth bass population. These computed metrics, when compared with data sets assembled for numerous largemouth bass populations in North America, provided no evidence of population-level impairment. Results of this study suggest that PCB tissue concentrations associated with effects in laboratory studies do not necessarily translate to detectable effects on largemouth bass populations in their natural environment.

Solid-phase synthesis and biochemical studies of O-boranophosphopeptides and O-dithiophosphopeptides.

Signal transduction cascades maintain control over important cellular processes such as cell growth and differentiation by orchestrating protein phosphorylation and dephosphorylation. Specific control of these processes in vivo and in vitro can be achieved with peptide analogues that mimic the binding properties of phosphoproteins. We present here the solid-phase synthesis of two novel classes of phosphopeptide mimetics, O-boranophosphopeptides and O-dithiophosphopeptides, derivatized on tyrosine, serine, and threonine. The use of H-phosphonate and H-phosphonothioate monoesters containing the base labile 9-fluorenemethyl protecting group was key to the synthesis of both phosphopeptide mimetics. O-Boranophosphopeptides were synthesized by condensing O-(9-fluorenemethyl)-H-phosphonate to the peptide hydroxylic component (tyr, ser, or thr) followed by oxidation with borane complexes. Similarly, the synthesis of O-dithiophosphopeptides used the O-(9-fluorenemethyl)-H-phosphonothioate synthon and oxidation with elemental sulfur. Base elimination of the Fmol protecting group and cleavage from the solid support with concentrated ammonium hydroxide afforded the boranophosphopeptide and dithiophosphopeptide target compounds. Ac-YIIPLPG-NH2, having either dithiophosphoryl tyrosine or boranophosphoryltyrosine but no sequence specificity for Yersinia protein tyrosine phosphatase (PTP), was found to competitively inhibit this enzyme with KI values of 430 +/- 50 and 670 +/- 50 microM, respectively. In addition, both phosphopeptide analogues were resistant toward Yersinia PTP enzymatic hydrolysis. Under conditions (pH 8.0) where the phosphopeptide was rapidly dephosphorylated, the boranophosphopeptide hydrolyzed slowly (t1/2 = 15 h) and the dithiophosphopeptide was completely stable over 24 h.

RELATIONSHIPS BETWEEN FREE CUPRIC ION CONCENTRATIONS IN SEA WATER AND COPPER METABOLISM AND GROWTH IN CRAB LARVAE.

Crab larvae (Rhithropanopeus harrisiiere exposed to a range of free cupric ion concentrations, [Cu2+], regulated in sea water by a metal chelate buffer system. We found a biphasic relationship between intracellular copper distribution and [Cu2+] in sea water. At [Cu2+] within the ambient range (10-12.4 to 10-10.6 M), cytosolic copper was associated with both metallothionein (MT) and high molecular weight (HMW) ligands, and was independent of external [Cu2+]. At higher [Cu2+], copper was also associated with very low molecular weight (VLMW) ligands, and accumulated in this ligand pool and the MT pool as external [Cu2+] increased. In marked contrast, copper in the HMW ligand pool did not correlate with [Cu2+] in sea water over the entire range of exposures. Reductions in larval growth occurred at greater than estimated ambient [Cu2+] and correlated with copper accumulation in the MT and VLMW pools.