The Impact of COVID-19 on Emergency Medicine Rotations.

Introduction The impact of modifications in curriculum and clinical rotations made secondary to the COVID-19 pandemic on medical education has yet to be fully investigated. We observed differences in the types of patients seen by medical students that may have resulted from clinical disruptions due to the COVID-19 pandemic. We then evaluated what impact these disruptions had on the students' clinical competency. Methods We obtained patient logbooks of third-year medical students (M3) and fourth-year sub-interns (M4) from the first three emergency medicine (EM) rotation blocks of the 2019-2020 (Y19) and 2020-2021 (Y20) academic years. We then reviewed and categorized the chief complaints seen and procedures in which they participated. A robust t-test was used to detect differences in chief complaints and procedures. Finally, we looked for objective differences using the chi-square test in clinical performance between the class of 2021 (Class21) and the class of 2022 (Class22), as assessed by performance on our institution's clinical competency examination. Results Overall, students saw a 25.3% decrease in average number of patient encounters. Statistically significant decreased average numbers of infectious (-28.3%, p=0.013); musculoskeletal (-22.2%, p=0.018); gastrointestinal (GI) (-24.6%, p<0.01); genitourinary (GU) (-33.2%, p<0.01); head, eyes, ears, nose, throat (HEENT) (-31.1%, p<0.01); trauma (-33.0%, p<0.01); and respiratory (-45.4%, p<0.001) complaints were observed. Both M3s and M4s encountered significantly less GU (-25.6%, p=0.048; -41.7%, p=0.016) and trauma (-29.1%, p=0.023; -33.2%, p=0.032) complaints in Y20. M4s saw significantly less GI complaints (-42.6%, p<0.001) in Y20, whereas M3s encountered significantly less psychiatric and HEENT complaints (-30.3%, p=0.046; -34.6%, p=0.013). Both classes saw significantly less respiratory complaints in Y20 but more so for M4s (-65.3%, p<0.001) than for M3s (-27.9%, p=0.033). There were no significant differences in average number of procedures between years. We did not observe any differences in overall clinical performance between the two selected classes. While class of 2021 scored a significantly higher average on a case of fatigue (p=0.0004) and class of 2022 on a case of abdominal pain (p<0.0001), there were no significant differences in the primary chief complaints that would be attributed to COVID-19, such as dyspnea. Conclusion Modifications made to curricula and clinical rotations due to the COVID-19 pandemic led to students encountering less patients overall, with significant decreases in multiple chief complaint types compared to Y19 but no significant change in procedure numbers. Notably, there was no major impact seen on clinical competency providing a positive argument for considering innovative teaching and learning methods.

Subcutaneous Sweet Syndrome Presenting as Cellulitis in a Pregnant Female.

We report a case of subcutaneous Sweet syndrome in a pregnant woman that was initially believed to be cellulitis. She was admitted after failure of symptom resolution following multiple oral antibiotics as an outpatient. Her rash continued to progress, and she became nauseous with a lack of appetite. Infectious disease, rheumatology, and dermatology were consulted. Skin biopsies were taken, and while awaiting results, due to continued disease progression despite broad-spectrum antibiotic coverage, IV steroids were started with rapid resolution. Eventual biopsy results showed a dense neutrophilic infiltrate in the subcutaneous fat in a lobular distribution without evidence of vasculitis, confirming a diagnosis of subcutaneous Sweet syndrome. This disease is exceedingly rare in pregnant patients, with few reported cases.

The Effect of Behavioural Indicators of Calf Discomfort Following Routine Procedures on Cow Maternal Care.

Pain causes altered arousal and specific behaviours that are rare at other times (pain indicators). We examined whether beef cows (mean age 6 years) are sensitive to pain indicators in addition to arousal following ear tagging and rubber ring castration (males only, n = 31) of their calf (n = 58). Behavioural pain indicators and activity were recorded continuously for 20 min before and 2 h after handling. The 30 min period posthandling captured the peak of behavioural change during this window. Cow maternal and maintenance behaviours were recorded for 20 min before and for 30 min after calf handling. Principal component (PC) analysis identified two dimensions (48% of the variance) in calf behaviour. Arousal and two active pain indicators loaded onto PC1 were shown by linear mixed models to positively affect some maternal behaviours. Lethargy, passive pain indicators and further active pain indicators loaded onto PC2 did not affect cow behaviour. Castration did not result in male calves receiving more maternal attention. Cows alter maternal behaviour in response to calf activity but not behaviours previously shown to indicate pain. Maternal care peaks soon after calving, but recent calving stress or the subtlety of neonatal behavioural expression may constrain cows in responding to the individual behavioural expression of their calf. Future studies exploring empathy should be aware of the constraints on behavioural expression associated with the neonatal and periparturient period.

Structural basis for alpha-conotoxin potency and selectivity.

Parkinson's disease is a debilitating movement disorder characterized by altered levels of alpha(6)beta(2) * ( * indicates the possible presence of additional subunits) nicotinic acetylcholine receptors (nAChRs) localized on presynaptic striatal catecholaminergic neurons. alpha-Conotoxin MII (alpha-CTx MII) is a highly useful ligand to probe alpha(6)beta(2) nAChRs structure and function, but it does not discriminate among closely related alpha(6) * nAChR subtypes. Modification of the alpha-CTx MII primary sequence led to the identification of alpha-CTx MII[E11A], an analog with 500-5300-fold discrimination between alpha(6) * subtypes found in both human and non-human primates. alpha-CTx MII[E11A] binds most strongly (femtomolar dissociation constant) to the high affinity alpha(6) nAChR, a subtype that is selectively lost in Parkinson's disease. Here, we present the three-dimensional solution structure for alpha-CTx MII[E11A] as determined by two-dimensional (1)H NMR spectroscopy to 0.13+/-0.09A backbone and 0.45+/-0.08A heavy atom root-mean-square deviation from mean structure. Structural comparisons suggest that the increased hydrophobic area of alpha-CTx MII[E11A] relative to other members of the alpha-CTx family may be responsible for its exceptionally high affinity for alpha6alpha4beta2 * nAChR as well as discrimination between alpha(6)beta(2) and alpha(3)beta(2) containing nAChRs. This finding may enable the rational design of novel peptide analogs that demonstrate enhanced specificity for alpha(6) * nAChR subunit interfaces and provide a means to better understand nAChR structural determinants that modulate brain dopamine levels and the pathophysiology of Parkinson's disease.