Epidermal nevi and epidermolytic hyperkeratosis: A review of cases, highlighting indications for biopsy and genetics referral.

Epidermal nevi are common benign cutaneous hamartomas that may rarely demonstrate histopathologic evidence of epidermolytic hyperkeratosis (EHK), representing cutaneous mosaicism for pathogenic keratin variants. Rarely, individuals with linear epidermal nevi transmit to their children the inherited form of EHK, also known as epidermolytic ichthyosis, characterized by generalized erythema, blistering, and scaling at birth evolving to widespread hyperkeratosis. We present an updated review of reported cases of linear epidermal nevi with EHK exhibiting transmission of epidermolytic ichthyosis to guide important considerations in the care of individuals with epidermal nevi. Clinical characteristics of linear epidermal nevi do not reliably predict the presence of EHK. All reported cases of transmission to offspring have occurred in individuals with linear epidermal nevi involving more than one anatomic area suggesting increased reproductive risk with involvement of two or more anatomic sites. Therefore, genetics consultation is recommended for these individuals with biopsy-confirmed EHK. For individuals with smaller areas of epidermal nevus involvement, the implications are less well known, though genetics consultation may still be considered for those interested in further discussion of general reproductive risk.

The relationship between acrochordons, obesity, and metabolic syndrome in the pediatric population: A retrospective cohort study.

BACKGROUND: Acrochordons or skin tags are common benign skin growths. Several studies explored the relationship between obesity and metabolic syndrome in adults but remains unexplored in children. METHODS: This was a single-center retrospective cohort study of outpatient dermatology patients between 1 January 2000 to 1 January 2021. Children under 18 years old diagnosed with acrochordons using diagnostic codes International Classification of Diseases, 10th Revision (ICD-10) L91.8 and 9th Revision (ICD-9) 701.8 were included. We collected patient demographics, past medical history, laboratory values, vital signs, and physical exam. Body mass index (BMI) was calculated and stratified into categories based on the Center for Disease Control's BMI-for-Age Growth Charts. Metabolic syndrome was diagnosed when three of the five criteria were met. Data were propensity-matched and compared with NHANES (National Health and Nutrition Examination Survey), which offered a generalizable sample to the US population. RESULTS: Fifty-five patients under 18 years old with a diagnosis of acrochordons were mostly Caucasian (76%) and female (64%). The mean BMI was 27.3, with 49.5% categorized as obese and 20% as overweight. The mean age of diagnosis was 10.1 years. Acrochordon predominantly appeared in the axilla. In our cohort, three patients (5.5%) met the criteria for metabolic syndrome. The prevalence of obesity (42% vs. 21%), type 2 diabetes mellitus (4.8% vs. 0.6%), hyperlipidemia (8.1% vs. 0%), and hypertension (1.6% vs. 0%) was greater in our cohort compared with NHANES. CONCLUSIONS: Like the adult population, acrochordons may serve as marker for metabolic disease in the pediatric population.

High-risk polysubstance use among LGBTQ+ people who use drugs in the United States: An application of syndemic theory.

BACKGROUND: Compared to heterosexual and cisgender people, lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people are more likely to develop problems with high-risk polysubstance use. According to syndemic theory, this disparity in high-risk polysubstance use is produced by the LGBTQ+ community's increased vulnerability to experiencing psychosocial (e.g., discrimination, unwanted sex) and structural (e.g., food insecurity, homelessness) conditions, greater likelihood of coping with concurrent health problems (e.g., human immunodeficiency virus [HIV]), and decreased opportunities to develop protective factors (e.g., social support, resilience). METHODS: Data from 306 LGBTQ+ participants living in the United States (U.S.) with a lifetime history of alcohol and drug use were analyzed; 21.2% reported lifetime problems with 10 different drugs. Bootstrapped hierarchical multiple regression was used to test demographic correlates and syndemic predictors of high-risk polysubstance use. One-way ANOVA and post-hoc comparison tests were used to test subgroup differences by gender. RESULTS: Results indicated that income, food insecurity, sexual orientation-based discrimination, and social support were associated with high-risk polysubstance use, explaining 43.9% of the variance of high-risk polysubstance use. Age, race, unwanted sex, gender identity-based discrimination, and resilience were not significant. Group comparison tests revealed that, compared to nonbinary people and cisgender sexual minority men and women, transgender individuals experienced significantly higher levels of high-risk polysubstance use and sexual orientation-based discrimination but significantly lower levels of homelessness and social support. CONCLUSION: This study provided further evidence for conceptualizing polysubstance use as an adverse outcome of syndemic conditions. Harm reduction strategies, anti-discrimination laws, and gender-affirming residential treatment options should be considered in U.S. drug policy. Clinical implications include targeting syndemic conditions to reduce high-risk polysubstance use among LGBTQ+ people who use drugs.

The relationship between estrogen and subsequent growth restriction among adolescents with heavy menstrual bleeding at menarche.

OBJECTIVES: We sought to evaluate the impact of estrogen-containing treatment for heavy menstrual bleeding (HMB) on subsequent height compared to progesterone-only or non-hormonal treatment when initiated at menarche. METHODS: We performed a retrospective chart review of adolescent females aged 10-15 years who presented to an institution-affiliated outpatient, inpatient, or emergency setting for management of HMB within three months of menarche. Growth records over a 2 year period starting at menarche were recorded, and comparisons made among patients treated with 1) estrogen, 2) progesterone, and 3) non-hormonal methods (controls). Groups were compared using bivariate analysis with Chi-square or Fisher's exact test and linear regression. RESULTS: In an analysis of 80 patients at 24 months, the mean increase in height from menarche was 6.4 cm among controls (n=54), 7.2 cm among the progesterone-only group (n=10), and 3.8 cm among the estrogen group (n=16). The estrogen group's increase in height was significantly lower than the control group's, by a mean of 1.8 cm (p=0.04). Change in height did not differ significantly between the progesterone and control groups (p=0.87). Additionally, for every year younger at menarche, there was 1 fewer cm of growth (change in height) at 24 months after menarche (p<0.002). CONCLUSIONS: Estrogen-containing treatment for HMB initiated within three months of menarche was associated with reduced growth at 24 months compared to progesterone-only or non-hormonal methods. The clinical applicability of the estrogen group's 1.8 cm absolute reduction in height may have considerable significance for those who are shorter at baseline.

Factorial Invariance of Scores on the Self-Objectification Beliefs and Behaviors Scale (SOBBS) Among Transgender and Nonbinary People.

The dimensionality and factorial invariance of scores on the Self-Objectification Beliefs and Behaviors Scale (SOBBS) were examined with a sample of 590 transgender and nonbinary participants. Results failed to disconfirm the two-factor model and provided adequate estimates of internal consistency reliability. Strong, strict, and structural invariance of scores were observed.

Labels improve emergency medicine physician comfort and ability to use a slit lamp.

Slit-lamp (SL) biomicroscopy is an important skill for emergency medicine (EM) clinicians. However, residents and faculty have varying levels of comfort and skill with this procedure. While some of the discomfort may be from a knowledge gap, we hypothesized that at least some difficulty came from infrequent use and forgetting which of the many knobs, levers, buttons, and switches of the SL create the desired effects. We strategically labeled a SL and tested the impact of this on the ability of 39 EM faculty and residents to identify a target on a maladjusted SL. Time to target identification was significantly lower with the labeled SL compared to the unlabeled SL, with median (IQR) time decreasing from 93 (31.5-154.5) seconds to 47 (0-141) seconds (p < 0.0001). Comfort level, as measured by a written survey and a graphic rating scale, also increased significantly with the labeled SL compared to the unlabeled SL.

Small-Scale High-Fidelity Simulation for Mass Casualty Incident Readiness.

Audience: This content can be used for trauma centers, emergency medicine residency programs, and emergency nursing. Introduction: Mass casualty incidents (MCI) are becoming increasingly common and are occurring in locations that have not experienced them previously which adds to the challenge of readiness for emergency departments (EDs). Sporadic occurrences and limited resources add to the complexity of preparing for such an event. In advance of a large gathering in our metropolitan area, we developed and conducted a simulation to better prepare not only our residents, but our MCI planning committee, registered nurses (RNs) and emergency room technicians (ERTs) for an MCI.Emergency medicine is at the forefront of any hospital's response to an MCI. These events stretch the resources and force EDs to function differently than usual.1 Responding effectively is crucial to minimizing the morbidity and mortality of our patients while maximizing use of available resources. We can improve our level-headedness, efficiency, and department and hospital-level planning through simulation. This has particular implications for residency training with effects on education, preparedness, and wellness. Educational Objectives: The learners will (1) recognize state of mass casualty exercise as evidenced by verbalization or triaging by START (Simple Triage and Rapid Treatment) criteria, (2) triage several patients, including critically ill or peri-arrest acuities, according to START criteria, (3) recognize the need to limit care based on available resources, as evidenced by verbal orders or communication of priorities to team, and (4) limit emergency resuscitation, given limited resources, by only providing treatments and employing diagnostics that do not deplete limited time, staffing, and space inappropriately. Educational Methods: A small-scale, high-fidelity simulation was created to replicate the pace and acuity of patients presenting in an MCI. Three critically injured patients with multiple gunshot wounds, represented by high-fidelity manikins with moulaged wounds, were presented over a 6-minute span. The team was allowed 10 minutes total to conduct life-saving measures, targeted evaluation, and disposition of the patients. The simulation was then adapted for use in a second institution's simulation center to replicate and validate the objectives given a different system. Research Methods: The learners were immediately verbally debriefed and feedback of the simulation, fidelity and appropriateness of the experience solicited. Unprompted, several of the learners volunteered that the efficacy of the experience was highly educational and valuable. Anonymized digital feedback was requested in the form of an online survey and was generally positive.The educational content was created by experts in simulation medicine and validated by content experts in the fields of Emergency Medicine, Trauma Surgery and Emergency Nursing. Results: After the scenario ended, the learners were taken to a second room for debriefing by a trauma surgeon, an emergency medicine attending, and the nurse trauma educator. The actors were able to participate as secondary learners and were rotated out of simulation duties to participate in the debriefing. After this twenty-minute educational debrief, the learners were brought back to the simulation bay and were given a similar scenario. After this iteration, the team debriefed a second time. This hour schedule of cases and debrief was repeated a total of four times with a total of twelve individual learners. Suggestions and verbal feedback were noted for incorporation into appropriate committees or hospital departments. No formal assessment was done and inclusion was strictly on a voluntary basis. An evaluation of the session (on a Likert scale of 1-5) had six respondents which showed an average of 5 on how educational the session was, 4.8 on how realistic the session was, and 4.8 on how effective the session was. Discussion: Simulation allows participants to safely gain practical experience in MCI management. The experience was well-received, and the learners verbalized increased confidence should they encounter an MCI in the future. We developed this simulation to give residents and nurses first-hand experience performing under high-stress, resource-limited conditions. We also had other learners observing the process which allowed for productive debriefing and planning for improvement. The ideas generated from this ultimately became part of the hospital's MCI response plan. The main takeaways were triage strategy and limited resource management. Topics: Mass casualty incident, mass gathering, penetrating trauma, high-fidelity simulation, team-based simulation, trauma center, hospital response planning.

Periodic Refresher Emails for Emergency Department Mass Casualty Incident Plans.

Audience and Type of Curriculum: This mass casualty incident (MCI) curriculum is intended for use as refresher content in the months between more formal education, such as hands-on MCI training and drills. The target audience for each topic varies, but the majority of them apply to all disciplines such as direct patient care roles (emergency room technicians, nurses, paramedics, advanced practice practitioners, resident physicians, attending physicians, etc.) and emergency department clerks/coordinators. Topics intended for only one or more discipline are labeled as such. See curriculum chart or email schedule (Appendix AI) for details. Length of Curriculum: This curriculum is intended for use as weekly refresher emails spanning up to a 30-week period. Introduction: There have been an increasing number of mass casualty events occurring throughout the country in recent years, many of which involve penetrating trauma. Education surrounding response to an MCI is broad and has many complex and ever-changing aspects that require staff to be updated on the most current information. Educational Goals: This curriculum is intended to maintain a knowledge base of MCI processes to mitigate degradation of necessary knowledge between hands-on MCI training. Educational Methods: The educational strategies used in this curriculum include short weekly refresher emails and optional external links for further reading. Research Methods: This content was evaluated for efficacy by administering electronic knowledge tests at baseline, mid-way (at 16 weeks), and at the end of the curriculum (32 weeks) via email. Additionally, brief content questions were asked in person while staff members were on shift throughout the entire study period, and a post-study survey was administered in order to obtain staff opinions on email length and training processes in general. Results: Scores for the knowledge tests were slightly higher at the end of the 32 weeks compared to baseline. Subjective feedback was positive overall at the end of the testing period. Discussion: Training and maintaining knowledge of roles and concepts of mass casualty incidents is vital since such events will never happen when expected. Short refresher emails allow educators to use spaced repetition and interleaving methods which have been shown to be a helpful adjunct to maintain knowledge, skills, and attitudes learned in more formal training.1,2. Topics: Mass casualty incident, emergency department, decontamination, blast injury, media relations, biological agents, reprocessing, crisis standard of care, SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) triage, personal protective equipment, disaster carts, airways, passive security, family reunification.

When the Learner Is the Expert: A Simulation-Based Curriculum for Emergency Medicine Faculty.

Emergency physicians supervise residents performing rare clinical procedures, but they infrequently perform those procedures independently. Simulation offers a forum to practice procedural skills, but simulation labs often target resident learners, and barriers exist to faculty as learners in simulation-based training. Simulation-based curricula focused on improving emergency medicine (EM) faculty's rare procedure skills were not discovered on review of published literature. Our objective was to create a sustainable, simulation-based faculty education curriculum for rare procedural skills in EM. Between 2012 and 2019, most EM teaching faculty at a single, urban, Level 1 trauma center completed an annual two-hour simulation-based rare procedure lab with small-group learning and guided hands-on instruction, covering 30 different procedural education sessions for faculty learners. A questionnaire administered before and after each session assessed EM faculty physicians' self-perceived ability to perform these rare procedures. Participants' self-reported confidence in their performance improved for all procedures, regardless of prior procedural experience. Faculty participation was initially mandatory, but is now voluntary. Diverse strategies were used to address barriers in this learner group including eliciting learner feedback, offering continuing medical education credits, gradual roll-out of checklist assessments, and welcoming expertise of faculty leaders from EM and other specialties and professions. Participants perceived training to be most helpful for the most rarely-encountered clinical procedures. Similar curricula could be implemented with minimal risk at other institutions.

Assessing the Informed Consent Skills of Emergency Medicine Resident Physicians.

BACKGROUND: Informed consent (IC) is an essential component of shared medical decision making between patients and providers in emergency medicine (EM). The basic components required for adequate consent are well described, yet little is published investigating whether EM residents demonstrate adequate IC skills. OBJECTIVE: The objectives were to assess the ability of EM residents to obtain IC for an invasive emergency procedure using a novel assessment tool and to assess reliability and validity of the tool. METHODS: This was an observational study in which participants were initially blinded to the primary objectives of the study. Each participant conducted a video-recorded history and physical examination with a standardized patient, requiring tube thoracostomy due to spontaneous pneumothorax. Two faculty EM physicians independently reviewed the videos and evaluated the participants' IC skills. First, they gave an overall impression of whether IC was obtained; they then evaluated the participants using a 30-point scoring tool based on the five elements of IC (decision-making capacity, disclosure, voluntariness, understanding, and physician recommendation). Upon all participants' case completion, we revealed the primary objectives and gave participants the option to withdraw from the study. Descriptive statistics and kappa coefficient were generated from the data collected. RESULTS: Twenty-two residents completed the study. None withdrew from the study after the primary objectives were revealed. Twenty residents (91%) obtained adequate IC based on both reviewers' overall impression. One disagreement occurred between reviewers (κ = 0.64). The mean IC score on a 30-point scale was 18.5 ± 0.5. CONCLUSIONS: In a simulated setting, most EM residents at this training program possess the knowledge and skills necessary to obtain IC prior to an invasive procedure. The assessment tool appears reliable and demonstrates construct validity.

Shoulder Dystocia Delivery by Emergency Medicine Residents: A High-fidelity versus a Novel Low-fidelity Simulation Model-A Pilot Study.

BACKGROUND: Shoulder dystocia (SD) requires emergent intervention to prevent maternal and fetal harm, and simulation models for training can be expensive. We developed a novel, cheap and easily transportable low-fidelity simulation (LFS) model to compare to a commercially available high-fidelity simulation (HFS) model. METHODS: Emergency medicine residents were randomized to training on the HFS or novel LFS model. Subjects completed a pretest and a 1-week and 6-month posttest including a self-assessment and a simulated SD delivery. RESULTS: Twenty-seven of the 43 residents completed the study (63%). The number of individuals performing dangerous maneuvers at baseline was similar, 1 week after training was five in HFS and 11 in LFS (p = 0.08) groups and at 6 months was again similar between groups. Mean checklist scores for appropriate actions increased 1 week after training but returned to baseline by 6 months and were similar between groups. The rate of successful delivery, median time to successful delivery, and maximum force applied improved at 1 week and was sustained at 6 months in both groups. CONCLUSION: Within our limited study population, we did not find a large difference in the occurrence of dangerous actions during simulated SD delivery following HFS and LFS training. Our novel and easily transportable LFS trainer, assembled for less than US$10 each, may be a useful tool to train inexperienced providers on the steps of this procedure. However, this requires further study, as does whether HFS models with force monitoring capabilities may be helpful to train providers to minimize dangerous maneuvers such as the application of excessive force.

Atrial flutter with 1:1 conduction in undiagnosed Wolff-Parkinson-White syndrome.

BACKGROUND: Atrial flutter with 1:1 atrioventricular conduction via an accessory pathway is an uncommon presentation of Wolff-Parkinson-White syndrome not previously reported in the emergency medicine literature. Wolff-Parkinson-White syndrome, a form of ventricular preexcitation sometimes initially seen and diagnosed in the emergency department (ED), can present with varied tachydysrhythmias for which certain treatments are contraindicated. For instance, atrial fibrillation with preexcited conduction needs specific consideration of medication choice to avoid potential degeneration into ventricular fibrillation. CASE REPORT: We describe an adult female presenting with a very rapid, regular wide complex tachycardia successfully cardioverted in the ED followed by a normal electrocardiogram (ECG). Electrophysiology study confirmed atrial flutter with 1:1 conduction and revealed an accessory pathway consistent with Wolff-Parkinson-White syndrome, despite lack of ECG findings of preexcitation during sinus rhythm. Why should an emergency physician be aware of this? Ventricular tachycardia must be the first consideration in patients with regular wide complex tachycardia. However, clinicians should consider atrial flutter with 1:1 conduction related to an accessory pathway when treating patients with the triad of very rapid rate (>250 beats/min), wide QRS complex, and regular rhythm, especially when considering pharmacologic treatment. Emergency physicians also should be aware of electrocardiographically concealed accessory pathways, and that lack of delta waves does not rule out preexcitation syndromes such as Wolff-Parkinson-White syndrome.

Evaluation of the Storz CMAC®, Glidescope® GVL, AirTraq®, King LTS-D™, and direct laryngoscopy in a simulated difficult airway.

OBJECTIVE: The aim of this study was to compare first-attempt and overall success rates and success rates in relation to placement time among 5 different airway management devices: Storz CMAC, Glidescope GVL, AirTraq, King LTS-D, and direct laryngoscopy (DL). METHODS: Emergency medical technician basic (EMT-B), EMT-paramedics (EMT-P), and emergency medicine residents and staff physicians placed each of the 5 devices in a random order into an AirSim (TruCorp, Belfast, UK) part-task training manikin. The difficult airway scenario was created by fixing the manikin head to a stationary object and introducing simulated emesis into the hypopharynx. First-attempt and overall success and success in relation to placement time were compared. Provider feedback about device performance was also evaluated. RESULTS: Ninety-four providers (16 EMT-basics, 54 EMT-paramedics, and 24 emergency department doctors of medicine) consented to participation. First-attempt and overall success rates for DL, King LTS-D, GVL, and CMAC were not statistically different. Compared with DL, the AirTraq was 96% less likely to be placed successfully (odds ratio, 0.04; 95% confidence interval [CI], 0.01-0.14). When time was factored into the model, the odds of successful placement of the King LTS-D were higher compared with DL (hazard ratio [HR], 1.80; 95% CI, 1.34-2.42) and lower for GVL (HR, 0.59; 95% CI, 0.44-0.80) and AirTraq (HR, 0.228; 95% CI, 0.16-0.325). Providers ranked the CMAC first in terms of performance and preference for use in their practice setting. CONCLUSION: Overall success rates for DL, King-LTS-D, and both video laryngoscope systems were not different. When time was factored into the model, the King LTS-D was more likely to be placed successfully.

Simulator training improves fiber-optic intubation proficiency among emergency medicine residents.

OBJECTIVES: The objective was to observe how a workshop using a virtual reality bronchoscopy simulator and computer-based tutorial affects emergency medicine (EM) resident skill in fiber-optic intubation. METHODS: In this observational before-and-after study, EM resident performance on three simulated pediatric difficult airway cases was observed before and after a short computer-based tutorial and 10 minutes of self-directed practice. The primary outcome was the total time required to place the endotracheal tube (ETT), secondary outcomes included the number of endoscope collisions with mucosa, and a calculated efficiency score measuring the proportion of time participants spent looking at correct central airway structures. Nonparametric Wilcoxon signed rank tests compared performance on the first versus the repeat attempt for each of the three simulated cases. Participants were surveyed regarding their assessments of the experience. RESULTS: Significant decreases in median procedure times and number of scope collisions and increases in median efficiency scores were seen for Cases 1 and 2. Case 3 showed no significant changes in outcomes between first and repeat attempts. Participants positively assessed the training and felt that its use would improve clinical practice. CONCLUSIONS: Participation in a simulation-based fiber-optic intubation skill workshop can improve fiber-optic intubation performance rapidly among EM residents. Future research should evaluate if this enhanced performance translates to improved clinical performance in the emergency department (ED).