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While stereotactic body radiation therapy (SBRT) or hypofractionated radiation therapy (HFRT) is routinely used to treat early-stage non-small lung cancer (esNSCLC) patients with peripheral tumors, SBRT or HFRT for central (cenT) and ultracentral tumors (UCT) remains controversial. To treat patients with tumors located within 0.5 cm to 2 cm of critical mediastinal structures, we often utilize an institution-specific hypofractionated regimen (isHFR) using 17 fractions to a dose of 6987 cGy. Our study seeks to evaluate the safety and efficacy of this fractionation scheme, while comparing patients' adverse-event free survival (AEFS), overall survival (OS), and progression free survival (PFS) outcomes to historical data. We conducted a single-institution retrospective review of patients with eNSCLC treated with isHFR between 2011 and 2019, evaluating rates of Grade 2 or higher hemoptysis (HP), bronchial stricture or necrosis (BSN), radiation pneumonitis and cardiotoxicity (CardT) based on CTCAE criteria. Kaplan Meier survival models were created to assess OS, AEFS and PFS in cenTs and UCTs. Differences were assessed using log-rank tests. Relative frequencies for categorical variables of interest were also dichotomized by tumor centrality and then compared using Fisher's Exact tests while continuous variables of interest were compared using Wilcoxon Rank Sum Tests. Of the 32 patients evaluated, 62.5% of patients enrolled had UCTs while 37.5% of enrolled patients had cenTs. The rate of locoregional control was noted to be 87.5% while rate of distant control was 78.1%. The probability of survival at 1 year was noted to be 75.0% while median OS was 19.3 months, 95% CI [13.94, 29.42]. Median OS for cenTs was 21.2 months and 18.2 months for UCTs, 95% CI [5.13, 31.76] and [11.77, 31.43] (p = 0.7706). AEFS at 12 months was 68.8%. 2 patients (6.3% of the cohort) experienced Grade 5 toxicity with 1 UCT patient experiencing Grade 5 BSN and the other cenT patient experiencing Grade 5 HP. Our patient who experienced BSN did so about 9 months following treatment and had noted PET avid recurrent disease in the mediastinum. The second patient experienced G5 hemoptysis approximately 1 year following treatment. The patient's most recent CT scan demonstrated post-radiation changes, although recurrent disease could not be excluded. She was scheduled for a PET CT but expired shortly before this study was performed. Only 1 patient (3.1% of the cohort) experienced CardT, a myocardial infarction, approximately 3 years following treatment. While this patient did not have a known coronary artery disease, he did have significant risk factors including hypertension and hyperlipidemia, as well as a strong family history. Our isHFR for patients with esNSCLC proves a safe and effective treatment for medically inoperable esNSCLC patients with cenTs and UCTs with comparable rates of toxicity when compared to historical norms, as well as notably low rates of cardiotoxicity. [ABSTRACT FROM AUTHOR]

Older patients with hormone receptor-positive, HER2-negative, early-stage breast cancer (HPEsBC) are routinely treated with breast-conserving surgery (BCS) followed by adjuvant radiation therapy (RT), oral endocrine therapy (ET), or both. However, for patients who are unable to complete a full 5-year course of ET, RT may improve oncologic outcomes. Our study of HPEsBC was undertaken to identify predictors of low ET compliance and to assess the role of RT in altering survival for older ET low-compliant patients. Using the nationwide Flatiron Health electronic health record-derived de-identified database, patients ≥ 65 years old with clinical or pathologic T1-2N0 HPEsBC treated with BCS from 2011-2018 were reviewed. Four adjuvant groups were identified: ET, RT, ET + RT, and no therapy. A 60-day landmark Kaplan-Meier (KM) curve and Cox proportional hazards model were used to compare OS. Low ET compliance was defined as ET taken for <4 years (compliance < 80%). Multinomial logistic regression then isolated predictors of ET compliance. Using the Cox model with ET compliance as a time-varying covariate, hazard ratios for compliance and radiation were determined while adjusting for age, race, ethnicity, socioeconomic status quintile, insurance, clinic visits, practice type, ECOG, tumor grade, and histology. The study group included 1,488 HPEsBC patients (354 ET, 118 RT, 894 ET + RT, and 122 no therapy). Low compliance was recorded for 287 of 1248 ET-treated patients (23%). In an unadjusted analysis, median OS (mOS) was greater for patients treated with ET + RT than for patients receiving ET alone, RT alone, or no therapy (mOS not reached, mOS 125.1 mos, mOS 120.3 mos, mOS 97.4 mos, respectively; P <0.001). When the effect of treatment was adjusted for all covariates, mortality was greater for RT alone and no therapy than for ET + RT (HR = 1.77, P = 0.011; HR = 2.53, P <0.001, respectively). Increasing age and treatment at an academic practice (vs community) were associated with low ET compliance (OR = 1.06, P <0.010; OR = 2.58, P <0.001, respectively). The Cox model with a time-varying covariate demonstrated an increased risk of mortality when ET compliance declined 10% (HR = 1.17, P <0.001). An interaction between compliance and RT showed no differential effect of radiation based on levels of compliance. Low compliance was observed in almost 1 in 4 HPEsBC patients ≥ 65 years old and was associated with advancing age and treatment at an academic center. Declines in ET compliance as small as 10% were associated with significantly increased mortality. Further study to identify a possible survival benefit from RT for elderly HPEsBC patients with ET compliance levels much lower than 80% is warranted. [ABSTRACT FROM AUTHOR]

Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Background: The primary objective of emergency medicine (EM) residency training is to develop knowledgeable, procedurally competent, and highly efficient physicians. We aimed to determine current overall productivity statistics and if there is an average rate of productivity change for individual residents as they progress through their training., Methods: This was a retrospective review of EM resident productivity performed at two American Council of Graduate Medical Education-accredited, community-academic residency programs from July 2012 to June 2018. Productivity was defined by relative value units (RVU)/h, RVU/patient, and patients/h. Mixed-effects models for repeated-measures data were used to assess change in outcome over postgraduate year (PGY) levels. The models included the interaction between progressive PGY levels to assess whether there was a pattern of change between each training year., Results: A total of 102 unique EM residents were included in the analysis. All three productivity measures increased linearly between PGY levels. However, while each graduating class had linear improvement throughout training, the rates of change were not consistent from one class to the next. Furthermore, a consistent rate of change between PGY for individual residents could not be established. Productivity can increase, decrease, stay the same, or any combination as residents advance through their training., Conclusions: Overall productivity of EM residents increases as they advance through their training. However, there is no consistent pattern of increase from one graduating class to the next and no reliable pattern of change for individual residents. Having increased granularity and understanding of productivity as it relates to individual residents will allow for more enhanced advisement of residents about their current productivity and their anticipated course through residency., Competing Interests: The authors have no potential conflicts to disclose., (© 2021 by the Society for Academic Emergency Medicine.)

Objectives: Self-assessment and self-directed learning (SDL) are integral to developing competent physicians who are lifelong learners. Individualized learning plans (ILPs) are tools to formalize this process and allow for mentors to guide residents in developing these skills. Pediatric residencies have adopted the ILP process and have demonstrated improvement in resident SDL behavior, but to date there have been no EM residencies to adopt the ILP process into resident education., Methods: The ILP program was designed around three key elements: (1) resident performance of self-assessment; (2) a collaborative conversation about learning needs and goals; and (3) a shared development of implementation strategies. The program was implemented with 12 PGY1 EM residents in the 2019-2020 academic year. Following an introduction to ILPs during orientation, residents met monthly with program leadership to create and reflect on ILPs. At the conclusion of the academic year, residents were surveyed about their attitude toward the ILP process and SDL., Results: A total of nine residents completed the postimplementation survey. Prior to implementing the ILP program, residents universally reported that they had little to no experience with generating an ILP. Following implementation, 55% of residents described themselves as strong independent learners and 89% wanted to continue the program into their second year., Conclusions: Overall, residents felt that the ILP program helped to focus their goals, monitor their progress, and allowed them to develop a relationship with program leadership., (© 2021 by the Society for Academic Emergency Medicine.)

Background: Effective feedback is the cornerstone of competency-based education. The emergency department (ED) is a unique learning and feedback environment. Developing our understanding of emergency medicine (EM) residents' experiences around feedback will improve resident training and inform EM faculty development programs., Objective: This qualitative study explores the feedback culture and practices in EM and resident's experiences and attitudes toward feedback in this specific training environment., Methods: At a large categorical EM program, 15 residents voluntarily participated in semistructured interviews regarding feedback. These individual interviews were performed by a nonphysician investigator and transcripts underwent an inductive multistep coding process. Transcripts were analyzed to identify common factors influencing feedback and then comparisons were made between residents to explore the interconnectedness of identified factors and further categorize consistent themes., Results: Factors inherent to the ED environment make the delivery of effective feedback challenging. Residents also revealed that feedback-seeking/-avoidant behavior and receptivity to feedback are multifactorial. Residents actively seek feedback when they feel that they performed well but tend to avoid feedback interactions when they expect constructive feedback. Finally, residents filter feedback based on attending personality and perceived practice style as well as their own desired practice style., Conclusions: It is important for program leaders to understand their residents' experiences with feedback and engage both faculty and residents in conversations around feedback delivery and receptivity. An improved understanding of these experiences might also reveal barriers to performance assessment and guide efforts to improve the accuracy and reliability of resident evaluations., Competing Interests: The authors have no potential conflicts to disclose., (© 2021 Society for Academic Emergency Medicine.)

Only recently have we begun to understand the ecological and evolutionary effects of urbanization on species, with studies revealing drastic impacts on community composition, gene flow, behaviour, morphology and physiology. However, our understanding of how adaptive evolution allows species to persist, and even thrive, in urban landscapes is still nascent. Here, we examine phenotypic, genomic and regulatory impacts of urbanization on a widespread lizard, the Puerto Rican crested anole (Anolis cristatellus). We find that urban lizards endure higher environmental temperatures and display greater heat tolerance than their forest counterparts. A single non-synonymous polymorphism within a protein synthesis gene (RARS) is associated with heat tolerance plasticity within urban heat islands and displays parallel signatures of selection in cities. Additionally, we identify groups of differentially expressed genes between habitats showing elevated genetic divergence in multiple urban-forest comparisons. These genes display evidence of adaptive regulatory evolution within cities and disproportionately cluster within regulatory modules associated with heat tolerance. This study provides evidence of temperature-mediated selection in urban heat islands with repeatable impacts on physiological evolution at multiple levels of biological hierarchy.

Background: The objective of the current study was to determine whether emergency medicine residents' United States Medical Licensing Examination (USMLE) scores are significantly associated with first-attempt passage of the American Board of Emergency Medicine (ABEM) qualifying (written) examination. We hypothesized that USMLE Step 2 Clinical Knowledge (CK) scores would be useful in predicting students who passed the ABEM qualifying examination on their first attempt., Methods: For this retrospective cohort study, we examined the data of residents who successfully completed training at two emergency medicine residency programs between the years 2002-2013. Because scores on the USMLE Step examinations varied greatly across years, we obtained means and standard deviations from the National Board of Medical Examiners. We subtracted the mean score for the year each resident took the examination from the resident's examination score, creating centered Step 1 and centered Step 2 CK scores., Results: A multivariate logistic regression analysis indicated that centered Step 2 CK scores could be used to predict the odds of passing the ABEM qualifying examination (odds ratio = 1.05 [95% confidence interval 1.02 to 1.08, P < 0.001]). Using a Step 2 CK score cutoff of 7 points lower than the mean yielded 64% sensitivity and 81% specificity for predicting passage of the ABEM written examination on the first attempt., Conclusion: Program directors and selection committees may wish to consider whether applicants' Step 2 CK scores are near the national average when making ranking decisions, as this variable is highly predictive of passing the ABEM qualifying examination on the initial attempt.

Introduction: A proper understanding of study design is essential to creating successful studies. This is also important when reading or peer reviewing publications. In this article, we aimed to identify and summarize key papers that would be helpful for faculty members interested in learning more about study design in medical education research., Methods: The online discussions of the 2016-2017 Academic Life in Emergency Medicine Faculty Incubator program included a robust and vigorous discussion about education study design, which highlighted a number of papers on that topic. We augmented this list of papers with further suggestions by expert mentors. Via this process, we created a list of 29 papers in total on the topic of medical education study design. After gathering these papers, our authorship group engaged in a modified Delphi approach to build consensus on the papers that were most valuable for the understanding of proper study design in medical education., Results: We selected the top five most highly rated papers on the topic domain of study design as determined by our study group. We subsequently summarized these papers with respect to their relevance to junior faculty members and to faculty developers., Conclusion: This article summarizes five key papers addressing study design in medical education with discussions and applications for junior faculty members and faculty developers. These papers provide a basis upon which junior faculty members might build for developing and analyzing studies., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

The purpose of this phenomenological qualitative study was to examine the quality of life among college students living with Type 1 diabetes (T1D). Inclusion criteria included age 18 to 24, current college student, and a diagnosis of T1D for at least 1 year. Semi-structured interviews were conducted, in-person and by phone. During these interviews, college students shared stories of living with T1D and its impact on their quality of life. Three major themes emerged, which included "planning ahead," "thinking positive," and "seeking support." These findings provide a better understanding of the transitional experience of living with T1D and the impact on perceived quality of life while attending college. Techniques and strategies aimed at the enhancement of perceived quality of life for college students living with T1D were identified. These findings will provide valuable insight for professionals working with this population., (© The Author(s) 2016.)

Background: The environment in the Emergency Department (ED) is chaotic, and physicians are expected to perform procedures amongst distractions., Objectives: Our aim was to prospectively determine the effects of various levels of noise distraction on the success and time to successful intubation of a simulator., Methods: Forty-five Emergency Medicine, Emergency Medicine/Internal Medicine, and Emergency Medicine/Family Medicine Residents were studied in background noise environments of <50 decibels (noise level 1), 60-70 decibels (noise level 2), and of >70 decibels (noise level 3). Residents attempted three intubations on a simulator in succession, with three randomized noise levels. Time, in seconds, to intubation was measured in each of the successful intubations. Generalized linear models were employed to examine associations between noise level and time to intubation by attempt., Results: Time to intubation decreased with each attempt (median = 25.9, 17.9, 14.4 for attempt numbers 1, 2, and 3, respectively). Decibel noise level was not associated with time to intubation (p > 0.6) or success rate (p > 0.1). Attempt number did not modify the association between noise and time to intubation (p-for-interaction = 0.16)., Conclusion: Noise level did not have an effect on time to intubation or intubation success rate, suggesting that noise levels in the ED do not affect provider ability to perform procedures. However, knowing that increased noise levels increase stress and impair the ability to communicate with team members, further study needs to be done to definitively conclude that noise does not affect provider performance in the ED setting., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Experiential learning theory and the Kolb Learning Style Inventory (Kolb LSI) have influenced educators worldwide for decades. Knowledge of learning styles can create efficient learning environments, increase information retention, and improve learner satisfaction. Learning styles have been examined in medicine previously, but not specifically with Emergency Medicine (EM) residents and attendings. Using the Kolb LSI, the learning styles of Emergency Medicine residents and attendings were assessed. The findings showed that the majority of EM residents and attendings shared the accommodating learning style. This result was different than prior studies that found the majority of medical professionals had a converging learning style and other studies that found attendings often have different learning styles than residents. The issue of learning styles among emergency medical residents and attendings is important because learning style knowledge may have an impact on how a residency program structures curriculum and how EM residents are successfully, efficiently, and creatively educated.

We studied the effects of recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSFrh) on the internal pH of granulocytes using the fluorescent probe BCECF. GM-CSFrh did not directly alter the resting pH of granulocytes isolated from the peripheral blood; however, when the cells were preincubated for 90 minutes with the growth factor and then activated with the chemotactic peptide N-formyl met leu phe (fMLP), they exhibited both an acceleration in the initial rate of acidification and a marked delay in realkalinization. The kinetic changes both in initial acidification and in subsequent realkalinization induced by GM-CSFrh priming were not prevented by protein synthesis inhibitors and were observed in granulocytes harvested from patients with both sex-linked and autosomal recessive chronic granulomatous disease (CGD). By directly quantitating H+ ion secretion, by monitoring the effects of sodium repletion on intracellular pH, and through use of the sodium channel inhibitors amiloride and dimethyl amiloride and the Na+/K+-ATPase inhibitor ouabain, we showed that the altered kinetics of intracellular acidification and alkalinization following fMLP stimulation of GM-CSFrh-primed granulocytes could not be accounted for by changes in transmembrane proton exportation regulated by the Na+/H+ antiport channel. Although the initial acidification following fMLP was abrogated by 2-deoxy-D-glucose in both GM-CSFrh-pretreated and GM-CSFrh-untreated granulocytes, retardation of the subsequent phase of alkalinization was observed in GM-CSFrh-primed cells even after inhibition of both glycolytic and mitochondrial metabolism. Our data indicate that the increased cytosolic acidification following fMLP stimulation in granulocytes "primed" with GM-CSFrh does not result from disordered proton excretion but instead from increased release of intracellular free acid which is only partially coupled to glucose catabolism or to the generation of superoxide anion (O2-).

When human granulocytes that have been primed with recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSFrh) are activated by ligands that stimulate the respiratory burst, the amount of superoxide anion (O2-) they generate is significantly increased. We have found that the accelerated rate of O2- release occurring under these conditions is accompanied by an antecedent increase in membrane depolarization. We examined the nature of the enhancement of membrane depolarization in GM-CSFrh-primed granulocytes and investigated its relationship to the increase in O2- generation by N-formyl methionylleucylphenylalanine (fMLP)-activated granulocytes. We found that augmented depolarization could not be accounted for by a change in the resting membrane potential induced by the growth factor and was still present after either blocking passive transmembrane Na+ movement with dimethylamiloride or by increasing the membrane's permeability to K+ with valinomycin. When their ability to depolarize was virtually eliminated by dissipating the transmembrane K+ gradient, GM-CSFrh-pretreated cells continued to generate more O2- after fMLP than did control cells. These results indicate that augmentation of the granulocyte's ability to generate O2- anions, which is induced by priming with GM-CSFrh, is independent both of the resting transmembrane potential and of alterations in the extent of membrane potential change induced by stimuli such as fMLP.

Elastase-induced emphysema is associated with changes in all components of connective tissue, including elastin. The abnormal restructuring of lung parenchyma that occurs after elastase administration in hamsters might reflect an abnormal balance of elastin, collagen, and glycosaminoglycan in lung parenchyma. To test this hypothesis, we measured total amounts and levels of accumulation over 24 hr of connective tissue elements in lung explants at several points over a 1-year period after a single elastase treatment in hamsters. We found acute, early changes in the metabolism of elastin, collagen, and glycosaminoglycan consistent with degradation of elastin and increased turnover of collagen and glycosaminoglycan. By day 21 after elastase treatment, lung elastin had returned to control values, then rose and stayed elevated throughout the remainder of the study period. Total collagen levels rose in both control and elastase-treated lungs by the same amount over the year period. However, incorporation of 14C-proline into collagen hydroxyproline was elevated only in elastase-treated lungs over the period of 21 to 360 days. Incorporation of 14C-glucosamine into glycosaminoglycan was greatest over the period of 1 to 5 days after treatment and total levels also peaked at this time. By day 21 both incorporation of glucosamine and total levels of glycosaminoglycan had returned to normal, where they remained. The ratios of glycosaminoglycan to elastin and glycosaminoglycan to collagen were calculated over the period of 21 to 360 days to determine whether the long-term relative balance of these components had changed in elastase-treated lungs. We found that a steady-state imbalance existed between heparan sulfate and collagen and heparan sulfate and elastin, suggesting that an inappropriate amount of heparan sulfate was present relative to the amounts of collagen and elastin. We conclude that administration of elastase results in changes in the long-term balance of lung connective tissue components.

We examined the rate and quantity of superoxide anion (O2-) generation by granulocytes harvested from the blood of patients before and after a 12-24 h constant intravenous infusion with recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSFrh). Seven previously untreated patients with sarcomas who exhibited no bone marrow involvement by their disease were studied. Granulocytes were harvested from the peripheral blood of each patient before and after intravenous infusion with GM-CSFrh. The total quantity of O2- produced and the kinetics of its release were then determined following in vitro activation of the cells by the chemotactic peptide N-formyl methionyl-leucylphenylalanine (fMLP) or by phorbol myristate acetate (PMA). In all cases, the amount of O2- generated and the rate of its release were significantly increased after GM-CSFrh infusion. Our findings indicate that intravenous administration of GM-CSFrh to patients heightens the functional responsiveness of circulating granulocytes.