ABSTRACT
Audience: Emergency medicine interns, medical students, and mid-level providers (physician assistants, nurse practitioners). Introduction: Shock is defined as a state of global tissue hypoxia and is typically the result of hypotension and circulatory system failure. A variety of disease states may ultimately culminate in hypotensive shock through one or more generally recognized mechanisms - hypovolemic, cardiogenic, obstructive, and/or distributive shock.1 These mechanisms differ significantly in terms of their pathophysiology and requisite treatment. While the effects of hypotensive shock are initially reversible, untreated hypotensive shock may rapidly progress to multiorgan failure and death. Hence, the ability to promptly recognize a state of hypotensive shock, identify the underlying mechanism, and administer appropriate therapies are skills required of those caring for critically ill patients.2The evaluation of hypotensive shock in the Emergency Department is relatively commonplace. Mortality rates associated with shock are high, ranging from 22.6% - 56.2%, depending upon the underlying etiology.3 For these reasons, the authors believe that a web-based learning module addressing topics related to hypotensive shock would be beneficial to healthcare professionals who are likely to encounter it in clinical practice. The web-based nature of the module would lend itself to convenient viewing and would allow for utilization as a just-in-time training modality. Presenting these topics in an animated format may also be a useful way of displaying the complex nature of cardiovascular physiology. Educational Objectives: By the end of this module, participants should be able to:Review basic principles of cardiovascular physiologyDescribe the four general pathophysiologic mechanisms of hypotensive shockRecognize various etiologies for each mechanism of hypotensive shockRecognize differences in the clinical presentation of each mechanism of hypotensive shockCite the basic approach to treatment for each mechanism of hypotensive shock. Educational Methods: This is a video podcast which conveys information through animated content. It is available to learners on demand and just-in-time for practice. It may be used as a stand-alone educational tool, as a primer to other instructional methods (eg, simulation, flipped classroom setting, or case discussions), or a just-in-time training tool. Research Methods: A small-scale study was performed to quantify the efficacy of this module as an educational tool. The learner group was comprised of a convenience sample of third-year medical students in the midst of their core clinical clerkships. All third-year students were eligible to participate, regardless of which core clerkship they were currently engaged in. Third-year students were contacted via email regarding participation. Participation was completely optional - no incentive was offered, and students were informed that participation would not in any way affect their clerkship grades. For these reasons, an Instructional Review Board review was not necessary. Ten third-year medical students volunteered to participate. In the course of a single, hour-long session, learners were administered the attached assessment form as a pre-test, shown the video module, and then asked to immediately retake the assessment as a post-test to assess for improvement. Assessments were graded on a 17-point scale, according to the attached answer key. Learners were also given the opportunity to provide subjective feedback on the quality of the module as an educational tool. Results: For this assessment, the maximum possible score was 17 points. The average pre-test score across all learners was 11.75 (69.12%) with a standard deviation of 3.24. The average post-test score across all learners was 15.12 (88.97%) with a standard deviation of 3.31. All learners demonstrated improvement in scores on the post-test, with a maximum and minimum improvement of 6 points and 1 point respectively. On average, learners improved by 3.38 points (p = 0.029, 95% confidence interval, 1.97 to 4.78). Statistical significance was established using a paired student's T-test. All learners agreed with the statement, "This module effectively taught concepts related to hypotensive shock." Learners were also given the opportunity to provide subjective feedback regarding the module and responded with statements like, "comprehensive review of the subject," and "very helpful review for clinical clerkships." Discussion: Data from learner assessments suggest that this module is effective in communicating concepts related to hypotensive shock. Learner satisfaction with the module was unanimous. These results suggest that this module would be effective as a standalone educational tool, or as a primer to other instructional methods. Areas of further investigation may include assessment of a larger learner population, assessment of learners at additional stages of clinical training, and assessment of long-term knowledge retention. Topics: Shock, hypotension, cardiovascular physiology, pulmonary artery catheterization, flipped classroom, asynchronous learning, emergency medicine.
ABSTRACT
BACKGROUND: Spiral metacarpal fractures can result in shortening of the metacarpal shaft, which may lead to extension lag at the metacarpophalangeal joint and reduced grip strength. These fractures have been surgically treated to restore metacarpal length; however, there are complications associated with surgery, postoperative management and wound healing, which further threaten power recovery in the hand. OBJECTIVE: To determine the effect of conservative management of un-operated, nonscissoring spiral metacarpal fractures. METHODS: Sixty-one consecutive patients presenting with nonscissoring spiral metacarpal fractures were treated nonoperatively and studied prospectively to determine the natural history of their power outcome. Thumb fractures and those requiring surgical intervention for scissoring were excluded. RESULTS: Follow-up data of a minimum of five months (mean follow-up 87 weeks) were available for 13 patients. Mean grip strength at final follow-up was 36.18 kg on the uninjured side and 36.58 kg on the injured side. The strength-difference values did not differ significantly from zero (P=0.72). CONCLUSION: The loss of metacarpal length associated with these fractures may not cause a power deficit sufficiently large to significantly affect grip strength and functional recovery in the hand. A prospective randomized controlled trial of operated versus unoperated, nonscissoring metacarpal fractures is warranted.
HISTORIQUE: Les fractures spiroïdes des métacarpiens peuvent provoquer un raccourcissement diaphysaire, qui peut s'associer à un déficit d'extension de l'articulation métacarpophalangienne et à une diminution de la force de préhension. Ces fractures peuvent être opérées pour rétablir la longueur du métacarpien, mais des complications sont liées à la chirurgie, à la prise en charge postopératoire et à la guérison, ce qui menace le rétablissement de la force de la main. OBJECTIF: Déterminer l'effet d'une prise en charge prudente des fractures spiroïdes non déplacées et non opérées des métacarpiens. MÉTHODOLOGIE: Soixante et un patients consécutifs ayant une fracture spiroïde non déplacée du métacarpien ont été soignés sans être opérés et ont fait l'objet d'une étude prospective pour déterminer l'évolution naturelle de la force de leur main. Les fractures du pouce et celles qui devaient être replacées par voie chirurgicale étaient exclues. RÉSULTATS: Les chercheurs possédaient des données de suivi colligées sur au moins cinq mois (suivi moyen de 87 semaines) au sujet de 13 patients. La force de préhension moyenne au dernier rendez-vous de suivi était de 36,18 kg du côté non blessé et de 36,58 kg du côté blessé. Ces différences ne variaient pas de manière significative par rapport à zéro (P=0,72). CONCLUSION: La diminution de la longueur du métacarpien associée à ces fractures ne limite peut-être pas assez la force de la main pour vraiment nuire à son rétablissement fonctionnel et à sa récupération. Il faudra effectuer un essai aléatoire et contrôlé prospectif des fractures non déplacées des métacarpiens qui sont opérées par rapport à celles qui ne le sont pas.
ABSTRACT
OBJECTIVE: The present study examined parents' reports of the frequency, nature, and outcome of pediatrician consultation and interventions about significant preschool behavior problems. METHOD: Parents were asked whether they consulted with their pediatric providers about disruptive behavioral problems during a longitudinal study of preschool children. RESULTS: Eighty 4-year-old children had parents who had consulted with their pediatricians versus 90 children whose parents did not. Children who eventually met criteria for attention-deficit hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) 2 years later, received different pediatric interventions at age 4 years than children who did not have a diagnosis, chi (2) = 9.28, based on parent report. Eighty-nine percent of children who were referred for evaluation or treatment by pediatricians later met criteria for ADHD or ODD. However, 56% of children who later met criteria for ADHD or ODD were not referred by age 4 years. CONCLUSION: Pediatricians were able to differentiate between preschool children with transient versus persistent behavioral problems significantly better than chance, though a large number of children with behavioral problems were not provided with early assistance or referrals. Additional research is needed to obtain data directly from pediatricians about their interventions and resources for this vulnerable population.
