Acute Angle-Closure Glaucoma Secondary to Vitreous Hemorrhage Diagnosed with the Aid of Point-of-Care Ultrasound.

BACKGROUND: Acute angle-closure glaucoma (AACG) caused by vitreous hemorrhage is a rare complication of intravitreal injection that often leads to permanent vision loss without prompt treatment. CASE REPORT: This is a case of vitreous hemorrhage with secondary AACG in an 80-year-old man who presented to the emergency department (ED) with pain and vision loss in his left eye after undergoing intravitreal injection to treat exudative macular degeneration. The diagnosis was made with the use of point-of-care ultrasound after intraocular pressure (IOP) was found to be significantly elevated in the left eye. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should have a high level of suspicion for AACG in patients who are diagnosed with a vitreous hemorrhage after intravitreal injection and should immediately measure IOP for elevation upon presentation to the ED.

Idiopathic Bilateral Internal Jugular Vein Thrombosis Diagnosed by Point-of-Care Ultrasound.

Internal jugular vein (IJV) thrombosis is an unusual condition, especially when it develops bilaterally. This is a case of bilateral IJV thrombosis in a 77-year old female who presented to the emergency department with neck and arm swelling after discontinuing apixaban and undergoing an oropharyngeal procedure. The diagnosis of bilateral IJV thrombosis was made with the use of point-of-care ultrasound to evaluate bilateral jugular vein distention and bilateral upper extremity pitting edema found on her physical examination.

Iatrogenic Aortic Dissection Presenting With Leg Pain Diagnosed With Point-of-care Ultrasound.

Iatrogenic aortic dissection (IAD) status-post-cardiac catheterization is a rare complication often isolated to the proximal aorta. This is a case of IAD isolated to the distal aorta in a 41-year-old female who presented to the emergency department with right leg pain after undergoing three cardiac catheterizations. The diagnosis of IAD was made upon discovery of an intimal flap in the distal aorta and femoral artery while performing a point-of-care ultrasound to evaluate for deep vein thrombosis.

Flipping the Classroom in Graduate Medical Education: A Systematic Review.

BACKGROUND: Flipped classroom (FC) instruction has become increasingly common in graduate medical education (GME). OBJECTIVE: The purpose of this study was to profile the use of FC in the GME setting and assess the current status of research quality. METHODS: We conducted a systematic literature search of major health and social science databases from July 2017 to July 2018. Articles were screened to ensure they described use of the FC method in an Accreditation Council for Graduate Medical Education-accredited residency program and included research outcomes. Resulting articles were analyzed, described, and evaluated for research quality using the Kirkpatrick framework and the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: Twenty-two articles were identified, all of which were recently published. Five were only indirectly related to FC methods. Most studies reported Kirkpatrick-level outcomes. Studies involving resident learner opinions were generally positive. Pre-posttest studies resulted in large positive improvements in knowledge or skills attainment. Control group study results ranged from large positive (1.56) to negative effects (-0.51). Average MERSQI scores of 12.1 (range, 8.5-15.5) were comparable to GME research norms. CONCLUSIONS: Varying methods for implementing and studying the FC in GME has led to variable results. While residents expressed a positive attitude toward FC learning, shortcomings were reported. Approximately half of the studies comparing the flipped to the traditional classroom reported better achievement under the FC design. As indicated by the MERSQI score, studies captured by this review, on average, were as rigorous as typical research on residency education.

Curated Collection for Educators: Five Key Papers about the Flipped Classroom Methodology.

The flipped classroom (FC) pedagogy is becoming increasingly popular in medical education due to its appeal to the millennial learner and potential benefits in knowledge acquisition. Despite its popularity and effectiveness, the FC educational method is not without challenges. In this article, we identify and summarize several key papers relevant to medical educators interested in exploring the FC teaching methodology. The authors identified an extensive list of papers relevant to FC pedagogy via online discussions within the Academic Life in Emergency Medicine (ALiEM) Faculty Incubator. This list was augmented by an open call on Twitter (utilizing the #meded, #FOAMed, and #flippedclassroom hashtags) yielding a list of 33 papers. We then conducted a three-round modified Delphi process within the authorship group, which included both junior and senior clinician educators, to identify the most impactful papers for educators interested in FC pedagogy. The three-round modified Delphi process ranked all of the selected papers and selected the five most highly-rated papers for inclusion. The authorship group reviewed and summarized these papers with specific consideration given to their value to junior faculty educators and faculty developers interested in the flipped classroom approach. The list of papers featured in this article serves as a key reading list for junior clinician educators and faculty developers interested in the flipped classroom technique. The associated commentaries contextualize the importance of these papers for medical educators aiming to optimize their understanding and implementation of the flipped classroom methodology in their teaching and through faculty development.

Identification of inflicted traumatic brain injury in well-appearing infants using serum and cerebrospinal markers: a possible screening tool.

OBJECTIVE: Inflicted traumatic brain injury (iTBI) is the leading cause of death from TBI in infants. Misdiagnosis of iTBI is common and results in increased morbidity and mortality. Biomarkers may be able to assist in screening infants who are at high risk for iTBI and whose injury might otherwise be missed. We investigated whether serum and/or cerebrospinal fluid (CSF) concentrations of neuron-specific enolase (NSE), S100B, and myelin-basic protein (MBP) are sensitive and specific for iTBI in high-risk infants. METHODS: A prospective case-control study was conducted of 98 well-appearing infants who presented with nonspecific symptoms and no history of trauma. Serum or CSF was collected. NSE, S100B, and MBP concentrations were measured by enzyme-linked immunosorbent assay. Abnormal marker concentrations were defined a priori. Patients were followed for 12 months to assess for subsequent abuse. RESULTS: Fourteen patients received a clinical diagnosis of iTBI. Using preestablished cutoffs, NSE was 77% sensitive and 66% specific and MBP was 36% sensitive and 100% specific for iTBI. S100B was neither sensitive nor specific for iTBI. Five patients who were not identified with iTBI at enrollment were identified at follow-up as being possible victims of abuse; 4 had an increased NSE concentration at enrollment. CONCLUSIONS: Serum and/or CSF concentrations of NSE and MBP may be useful as a screening test to identify infants who are at increased risk for iTBI and may benefit from additional evaluation with a head computed tomography scan. S100B is neither sensitive nor specific for iTBI in this study population. The ability to identify iTBI that might otherwise be missed has important implications for decreasing the morbidity and the mortality from iTBI.

Serum neuron-specific enolase, S100B, and myelin basic protein concentrations after inflicted and noninflicted traumatic brain injury in children.

OBJECT: Misdiagnosis of inflicted traumatic brain injury (iTBI) is common. Serum biomarkers may be able to assist in the detection of iTBIs that would otherwise be missed. The authors investigated whether serum concentrations of biomarkers were increased after noninflicted (n)TBI and iTBI in pediatric cases of varying severity. METHODS: This prospective, case-control study involved 100 patients (56 with nTBI, 44 with iTBI) and 64 controls. Blood was collected in patients within 12 hours of injury; a subset had serial samples. A single sample was collected from controls. Serum neuron-specific enolase (NSE), S100B, and myelin basic protein concentrations were measured. Abnormal concentrations were defined using receiver-operator characteristic (ROC) curves. The sensitivity and specificity of initial NSE and S100B and peak myelin basic protein concentrations for identifying TBI at ROC curve-defined cutoffs were 71 and 64% (NSE), 77 and 72% (S100B), and 44 and 96% (myelin basic protein), respectively. Eighty-six percent of patients having suffered iTBI had one or more biomarkers increased, including 82% of children with iTBI and a Glasgow Coma Scale score of 15, and two children with iTBI who were initially misdiagnosed. Children with iTBI had a later peak concentration of all three biomarkers and were more likely to have increased myelin basic protein levels at admission compared with patients with nTBI. CONCLUSIONS: Serum NSE, S100B, or myelin basic protein are increased in the majority of children with acute nTBI and iTBI, including well-appearing children with iTBI in whom the diagnosis might otherwise have been missed. Differences in the time course of NSE, S100B, and myelin basic protein after nTBI and iTBI may provide insight into the pathophysiology of iTBI. These serum markers should be prospectively evaluated in a target population of infants.

Implementation of a program to teach pediatric residents and faculty about domestic violence.

OBJECTIVES: To obtain information about pediatric resident and staff knowledge, attitudes, and screening practices related to domestic violence (DV), to implement a domestic violence education program, and to evaluate whether the program resulted in changes in these 3 domains. DESIGN: Interventional with before and after survey evaluation. SETTING: A hospital-based, pediatric residency continuity clinic that serves families in Pittsburgh, Pa. PARTICIPANTS: Pediatric residents (n = 51), medicine-pediatric residents (n = 6), continuity clinic faculty (n = 22), and certified-registered nurse practitioners (n = 5). RESULTS: Prior to implementation of the DV education program, respondents correctly answered questions about the prevalence of DV (74 participants [90%]), the racial distribution of DV victims (66 participants [80%]), and the significant overlap between child abuse and DV (75 participants [91%]). Seventy-nine participants (96%) believed that screening for the presence of DV was part of their role as pediatric health care providers. At baseline, 17 (21%) of the 82 participants reported that they were routinely screening for signs of DV during well-child care visits compared with 39 (46%) after attending the education program (P =.005). Among participants who attended both educational session 25% (9/36) were routinely screening for the presence of DV prior to the intervention, compared with 46% (16/35) after the intervention (P =.008). At baseline, 33 (40%) of the 82 participants had identified at least 1 case of DV in the prior 6 months compared with 45 (53%) after training. Prior to training, 18 participants (22%) were aware of resources for DV victims compared with 45 (53%) after training (P<.001). CONCLUSIONS: To our knowledge, this is one of the first pediatric studies to demonstrate that using a short, multifaceted educational module, it is possible to change DV screening practices and to increase identification of DV victims among pediatric residents, continuity clinic faculty, and certified-registered nurse practitioners at a pediatric teaching hospital.