Search

Leslie A Bilello,1 Nicole M Dubosh,1 Jason J Lewis,1 Matthew M Hall,1 Jonathan Fisher,2 Edward A Ullman1 1Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; 2Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ, USA Background: The art of physical examination is one of the most valuable diagnostic tools bestowed upon new generations of medical students. Despite traditional educational techniques and significant attention on a national level, both trainees and educators have noticed a decrease in physical examination proficiency. Simulation has been identified as a potential way to improve physical examination techniques within undergraduate medical education. We sought to determine the utility of a cardiac case-based simulation scenario to assess physical examination performance of fourth-year medical students during an emergency medicine (EM) clerkship.Materials and methods: Fourth-year medical students enrolled in a 4-week EM clerkship were prospectively evaluated during a case-based scenario using a simulation mannequin (Laerdal SimMan®). The case involved a patient presenting with chest pain that evolved into cardiac arrest. All simulations were video recorded and two emergency physicians reviewed each video. The reviewers recorded whether or not each student completed the essential components of a focused physical examination.Results: Twenty-seven students participated in the simulation. The percentage of students completing each of the four components of the physical examination was as follows: cardiac auscultation 33.3% (95% CI 18.5–52.3), lung auscultation 29.6% (95% CI 15.7–48.7), pulse and extremity examination 55.6% (95% CI 37.3–72.4), and abdominal examination 3.70% (95% CI 0–19.8). None of the students completed all four of these components.Conclusion: Our study showed that fourth-year medical students did not uniformly perform components of a focused physical examination during a high-acuity chest pain simulation scenario. Although our study showed limited physical examination performance, simulation allows evaluators to observe and provide constructive feedback and may lead to an improvement in these skills. These findings call for improved technology to increase authenticity of simulators and continued faculty development for more creative, meaningful integration of physical examination skills into high-acuity simulation cases. Keywords: emergency medicine, medical student education, undergraduate medical education, physical examination skills

The authors have previously shown that it is possible to incorporate silver into a soda-zinc-silicate glass and subsequently form a glass polyalkenoate cement from it. The objective of the research described herein is to determine if incremental increases in the silver content of these glass polyalkenoate cements will increase their antibacterial efficacy against gram-positive and gram-negative bacteria using the accepted spread plate method. Four glass polyalkenoate cements were formulated; three contained increasing amounts of silver incorporated into them (cements A, B, and C, containing 0.33 mol%, 0.66 mol%, and 0.99 mol% silver, respectively) and a fourth contained no silver, which acted as a control (control cement). The handling properties of the glass polyalkenoate cements were evaluated, where working times were around 2 min and setting times ranged from 1 h 17 min to 2 h 41 min. Inductively coupled plasma atomic emission spectroscopy was employed to determine silver ion release with cement maturation for up to 14 days. The majority of silver ions were released within the first 24 h, with up to 2 mg/L cumulative ion release recorded up to 14 days. The antibacterial properties of the coatings were evaluated against Staphylococcus aureus and Pseudomonas aeruginosa bacteria. The silver-glass polyalkenoate cements exhibited antibacterial effect against both bacterial strains. The maximum inhibition zones recorded against S. aureus was 14.8 mm (SD ± 1.11) and against P. aeruginosa was 20.6 mm (SD ± 0.81). Cement B had a greater antibacterial effect compared to cement A, however, cements B and C had comparable antibacterial effects after 14 days even though cement C contained 0.33 mol% more silver than B. This indicates that by increasing the silver content in these cements, the antibacterial efficacy increases to a point, but there is a threshold where further silver ion release does not increase the antibacterial effect. [ABSTRACT FROM AUTHOR]

SYNOPSIS: Clinical practice guidelines for Achilles tendinopathy do not recommend imaging to inform diagnosis. However, there is considerable variation in how imaging is used, particularly in research and sports. Early imaging risks that people who see the images presume that what they "see" as pathology is the primary cause of pain; patients might end up receiving invasive treatments on the basis of the image when rehabilitation may suffice. On the other hand, imaging can help rule out Achilles tendinopathy and identify differential diagnoses. As more rehabilitation clinicians are direct access practitioners and take on expanded roles as primary health practitioners, ultrasound imaging might serve as a valuable point-of-care tool for diagnosis, identifying conditions that warrant referral and managing conditions like Achilles tendinopathy. We argue that the value of ultrasound imaging to diagnose tendinopathy outweighs the potential limitations. J Orthop Sports Phys Ther 2024;54(1):1-4. Epub 16 November 2023. doi:10.2519/jospt.2023.12255 .

Objectives: To 1) determine the types and frequency of complications within 3 months following ultrasound-guided surgical procedures, and 2) identify any patient demographics, co-morbidities, or procedural characteristics that were associated with an increased risk of complications., Methods: A retrospective chart review was performed at six Sports Medicine clinics across the United States. The Clavien-Dindo classification was used to categorize procedural complications on a 5-point scale from 1, representing any deviation in post-procedure care without requiring pharmacological or invasive treatment to 5, representing death. Generalized Estimating Equations for binomial outcomes with a logit link were used to estimate the overall and procedure-specific 3-month complication rates., Results: Among 1902 patients, 8.1% (n = 154) had diabetes and 6.3% (n = 119) were current smokers. The analysis included 2,369 procedures, which were performed in either the upper extremity (44.1%, n = 1045) or lower extremity (55.2%, n = 1308) regions. The most common procedure was ultrasound-guided tenotomy (69.9%, n = 1655). Additional procedures included, trigger finger release (13.1%, n = 310), tendon scraping (8.0%, n = 189), carpal tunnel release (5.4%, n = 128), soft tissue release (2.1%, n = 50), and compartment fasciotomy (1.6%, n = 37). Overall, there was a complication rate of 1.2% (n = 29 complications; 95% CI: 0.8-1.7%). Individual procedures had complication rates that ranged from 0 to 2.7%. There were 13 Grade I complications in 13 patients, 12 Grade II complications in 10 patients, 4 Grade III complications in 4 patients, and 0 Grade IV or V complications. No associations between complication risk and any patient demographics (age, sex, BMI), co-morbidities (diabetes, smoker), or procedure characteristics (type, region) were identified., Conclusion: This retrospective review provides an evidence-based estimate supporting the low level of risk associated with ultrasound-guided surgical procedures for patients from a variety of geographical settings who are seeking care at private and academic-affiliated clinics., (© 2023 The Authors. Journal of Ultrasound in Medicine published by Wiley Periodicals LLC on behalf of American Institute of Ultrasound in Medicine.)

Objectives: To determine the inter-rater reliability and criterion validity of two-dimensional (2D) measures of ankle function in the sagittal plane for participants with Achilles tendinopathy (AT)., Design: Cohort study., Setting: University Laboratory, Participants, Adults with AT (N = 18, Women: 72.2%, Age = 43.4 ± 15.8 years, BMI = 28.7 ± 8.9 kg/m 2 ) MAIN OUTCOME MEASURES: Reliability and validity were determined with intra-class correlation coefficients (ICC), standard error of the measurement (SEM), minimal detectable change (MDC), and Bland-Altman plots for ankle dorsiflexion and positive work during heel raises., Results: Inter-rater reliability between three raters for all 2D motion analysis tasks was good to excellent (ICC = 0.88 to 0.99). Criterion validity between 2D and 3D motion analyses for all tasks was good to excellent (ICC = 0.76 to 0.98). 2D motion analysis overestimated ankle dorsiflexion motion by 1.0-1.7° (3% of mean sample value) and positive ankle joint work by 76.8 J (9% of mean) compared to 3D motion analysis., Conclusion: Although 2D and 3D measures are not interchangeable, the good to excellent reliability and validity of 2D measures in the sagittal plane support the use of video analysis to quantify ankle function for individuals with foot and ankle pain., Competing Interests: Declaration of competing interest M. Hall receives royalties from UpToDate, Inc., holds stock in Trice Medical and Sonex Health, and serves on the Medical Advisory Board for Trice Medical and the Scientific Advisory Board for Vitruvia. Other authors declare no conflicts of interest for this study., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: The purpose of this study was to compare the efficacy of physical therapy delivered via an all telehealth or hybrid format with an all in-person format on movement-evoked pain for individuals with chronic Achilles tendinopathy (AT)., Methods: Sixty-six individuals with chronic AT participated (age, 43.4 [SD = 15.4] years; 56% female; body mass index, 29.9 [SD = 7.7] kg/m2). Participants completed all in-person visits from the initiation of recruitment in September 2019 to March 16, 2020 (in-person group). From March 17 to July 15, 2020, participants completed all telehealth visits (telehealth group). From July 16, 2020, to enrollment completion in December 2020, participants could complete visits all in-person, all telehealth, or a combination of in-person and telehealth (hybrid group) based on their preference. A physical therapist provided 6 to 7 visits, including an exercise program and patient education. Noninferiority analyses of the telehealth and hybrid groups compared with the in-person group were completed for the primary outcome of movement-evoked pain during single-limb heel raises., Results: All groups demonstrated decreases in movement-evoked pain beyond the minimal clinically important difference from baseline to 8 weeks (2 out of 10 on a numeric pain rating scale). Lower bounds of the 95% CIs for mean differences between groups did not surpass the preestablished noninferiority margin (2 out of 10) for movement-evoked pain in both the telehealth and hybrid groups (telehealth vs in-person: 0.45 [-1.1 to 2.0]; hybrid vs in-person: 0.48 [-1.0 to 1.9])., Conclusion: Individuals with chronic AT who completed a tendon-loading program with patient education through a telehealth or hybrid format had no worse outcomes for pain than those who received the same intervention through in-person visits., Impact: Physical therapist-directed patient care delivered via telehealth may enhance accessibility to best practice AT rehabilitation, including exercise and education. Use of telehealth technology may also provide an opportunity to prioritize patient preference for physical therapy visit format., Lay Summary: If you are a patient with chronic AT, physical therapist-directed patient care delivered via telehealth may improve your accessibility to best practice AT rehabilitation, including exercise and education. Use of telehealth technology may also prioritize your preferences regarding the format of the physical therapy visit., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: Medical educators in residency programs have unique opportunities to teach health inequities, social determinants of health (SDOH), and implicit bias. However, faculty are not adequately trained to effectively teach these topics. The aim is to assess the effectiveness of a faculty-level workshop to teach health inequity., Methods: An interactive workshop was designed by an interprofessional faculty from a major urban teaching hospital, addressing SDOH, implicit bias, an "Enhanced Social History," and the benefits of interprofessional care. Before and after completion, workshop participants completed surveys regarding comfort in teaching these concepts. Survey results were analyzed to assess benefits of the intervention., Results: Sixty-four percent of participants completed preworkshop and postworkshop surveys. Participants reported increased contemplation and improved comfort in teaching SDOH, barriers to medical care, and implicit bias., Conclusion: Faculty comfort in teaching health inequity increased after this workshop. This may help bridge the gap between the expectation of clinical faculty to evaluate trainee practice of patient-centered, culturally competent care, and faculty possession of and confidence in health inequity teaching skills in clinical settings. Future research should focus on learner- and patient-based outcomes, including teaching time and impact on delivery of care., Competing Interests: Disclosures: The authors declare no conflict of interest., (Copyright © 2022 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education, and the Society for Academic Continuing Medical Education.)

Objectives: The current lack of agreement regarding standardized terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice, and research. This consensus was developed to provide a reference to improve clarity and consistency in communication., Methods: A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus which was defined as group level agreement >80%., Results: Content was organized into seven general topics including: 1) General Definitions, 2) Equipment and Transducer Manipulation, 3) Anatomic and Descriptive Terminology, 4) Pathology, 5) Procedural Terminology, 6) Image Labeling, and 7) Documentation. Terms and definitions which reached consensus agreement are presented herein., Conclusions: The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients, and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine., (© 2022 American Institute of Ultrasound in Medicine.)

Medical learners are vital to the care of critically ill patients in the intensive care unit (ICU). Although these learners are exposed to the challenges and stresses of acute ICU management, they do not typically experience the benefits of following ICU patients and families longitudinally after their ICU rotation. Post-ICU clinics and recovery programs may fill this crucial gap in trainee education. These clinics have emerged as an appealing approach to potentially support patient recovery, enhance provider satisfaction, and provide feedback on vital lessons learned in long-term follow-up to improve the quality of ICU care. Notably, the effect of such a program on trainee education has not been explored. In this article, we propose a framework for medical learner participation in post-ICU follow-up based on the Accreditation Council for Graduate Medical Education milestones and discuss the potential benefits, including: education about post-ICU recovery, including post-intensive care syndrome and post-intensive care syndrome-family; experience in quality improvement to enhance ICU care by understanding long-term outcomes; engagement in reflection; and mitigation of compassion fatigue and burnout., (Copyright © 2022 by the American Thoracic Society.)

Sports ultrasound is commonly used by sports medicine physicians to enhance diagnostic and procedural accuracy. This expert consensus statement serves as an update to the 2015 American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Although written in the context of the American sports medicine fellowship training model, we present a stepwise progression in both diagnostic and interventional sports ultrasound that may be applicable to the broader sports medicine community. The curriculum is divided into 12 units with each unit including didactic instructional sessions, practical hands-on instruction, independent scanning practice sessions and mentored clinical experience. To assist with prioritisation of learning, we have organised relevant pathology and procedures as essential , desirable and optional The expanded content can serve as an outline for continuing education postfellowship or for any physician to further advance their sports ultrasound knowledge and skill. We also provide updated scanning protocols, sample milestones and a sample objective structured clinical examination to aid fellowships with implementation of the curriculum and ongoing assessment of fellow progress., Competing Interests: Competing interests: MMH reports personal fees from Tenex Health, personal fees from Sonex Health, other from UpToDate, Inc, outside the submitted work. JTF reports other from DEMOS Publishing, other from up to date, personal fees from COVR Medical, personal fees from Sanofi, personal fees from Aim Specialty Health, outside the submitted work. KM reports personal fees from McGraw Hill, personal fees from Elsevier, other from Tenex, outside the submitted work. JS reports other from Sonex Health, other from Tenex Health, outside the submitted work., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Ultrasound guided tenotomy (USGT) is a minimally invasive treatment option for patients with chronic tendinopathy. There are conflicting findings in the literature with some studies reporting severe complications and others reporting none. This variability is likely due to the small sample sizes of previous studies. We aimed to evaluate the risks associated with USGT and outcomes across multiple tendinopathy/fasciopathy sites in a large clinical sample., Methods: Patients who had USGT were identified by retrospective review of charts. Complications, satisfaction, and outcomes (pain, quality of life) were assessed at baseline prior to the procedure (outcomes only), short-term follow up, and long term follow up., Results: A total of 262 patients with 289 procedures were identified through chart review. There was a low complication rate of 0.7% including one superficial wound infection and one case of wound hypersensitivity. The majority of patients reported improvement in pain by short-term and long-term follow-up and improvement in function by long-term follow-up. The majority of responders reported being either 'very satisfied' or 'somewhat satisfied' with the procedure at short-term follow-up., Conclusion: This study found that USGT is a safe procedure with a low complication rate in a heterogeneous sample. Study findings provide preliminary evidence on the utility of USGT to reduce pain and improve function with a high rate of patient satisfaction. Level of Evidence: IV., (Copyright © The Iowa Orthopaedic Journal 2021.)

Background: Gun violence in the United States is a significant public health concern. The high rate of weapons carriage by Americans places medical providers at risk for exposure to firearms in the workplace and provides an opportunity for patient safety counseling. Few curricular interventions have been published on teaching firearms safety principles to medical providers. Given the risk of encountering firearms in the workplace and the opportunity to engage patients in firearms safety counseling, providers may benefit from dedicated training on safely handling firearms., Methods: This was a prospective cohort pilot study of a simulation-based educational intervention for third- and fourth-year medical students enrolled in an emergency medicine subinternship and emergency medicine bootcamp elective. Before undergoing the educational intervention, students completed a preintervention simulation case during which they discovered a model firearm in the patient's belongings and were asked to remove it. Students then received the intervention that included a discussion and demonstration on how to safely remove a firearm in the clinical setting. Two weeks later, the students were presented with a model firearm in a different simulation case, which they needed to remove. During the preintervention and postintervention simulations, students were evaluated on their performance of the critical actions in firearm removal using an 8-item checklist. Students' scores on this checklist were compared., Results: Fifty-three students participated in the study, 25 of whom completed the postintervention assessment. The median number of correctly performed critical actions preintervention was 5 (interquartile range = 4-6) and postintervention was 7 (interquartile range = 6-8, P < 0.001). Students showed particular improvement in 4 steps: holding the firearm by the grip only, pointing the firearm in a safe direction at all times, removing the firearm from the immediate patient care area and placing it in a safe area, and ensuring that the firearm is monitored and untouched until police or security personnel arrive to secure it., Conclusions: This educational intervention is the first to formally teach students about the safe handling of firearms found in the clinical care space. This low-cost pilot project is easily transferrable to other training centers for teaching principles of safe firearms handling., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Society for Simulation in Healthcare.)

Introduction: Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context., Methods: We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method., Results: From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow)., Conclusions: Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.

Abstract: Sports ultrasound is commonly used by sports medicine physicians to enhance diagnostic and procedural accuracy. This expert consensus statement serves as an update to the 2015 American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Although written in the context of the American sports medicine fellowship training model, we present a stepwise progression in both diagnostic and interventional sports ultrasound that may be applicable to the broader sports medicine community. The curriculum is divided into 12 units with each unit including didactic instructional sessions, practical hands-on instruction, independent scanning practice sessions, and mentored clinical experience. To assist with prioritization of learning, we have organized relevant pathology and procedures as essential, desirable, and optional. The expanded content can serve as an outline for continuing education postfellowship or for any physician to further advance their sports ultrasound knowledge and skill. We also provide updated scanning protocols, sample milestones, and a sample objective structured clinical examination (OSCE) to aid fellowships with implementation of the curriculum and ongoing assessment of fellow progress., Competing Interests: M. M. Hall reports personal fees from Tenex Health, personal fees from Sonex Health, and other from UpToDate, Inc, outside the submitted work. J. T. Finnoff reports other from DEMOS Publishing, other from UpToDate, personal fees from COVR Medical, personal fees from Sanofi, and personal fees from Aim Specialty Health, outside the submitted work. K. R. Mautner reports personal fees from McGraw Hill, personal fees from Elsevier, and other from Tenex, outside the submitted work. J. Smith reports other from Sonex Health and other from Tenex Health, outside the submitted work. The remaining authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The utility of ultrasound in sports medicine is improving the sports medicine physician's ability to rapidly diagnose and treat a multitude of sports related pathologies. In this article, we clearly outline the current status of the evidence in support of using sports ultrasound in the setting of acute ocular injury, evaluation of elevated intracranial pressures, deep venous thrombosis, and soft tissue complaints.

Background: Achilles tendinopathy (AT) rehabilitation traditionally includes progressive tendon loading exercises. Recent evidence suggests a biopsychosocial approach that incorporates patient education on psychosocial factors and mechanisms of pain can reduce pain and disability in individuals with chronic pain. This is yet to be examined in individuals with AT., Objective: This study aims to compare the effects on movement-evoked pain and self-reported function of pain education as part of a biopsychosocial approach with pathoanatomical education for people with AT when combined with a progressive tendon loading exercise program., Methods: A single-site, randomized, double-blind, placebo-controlled clinical trial will be conducted in a university-based hospital in a laboratory setting and/or by telehealth. A total of 66 participants with chronic (>3 months) midportion or insertional AT will be randomized for the Tendinopathy Education of the Achilles (TEAch) study. All participants will complete progressive Achilles tendon loading exercises over 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. All participants will complete 6-7 one-to-one sessions with a physical therapist to progress exercises in a standardized manner over 8 weeks. During the last 4 weeks of the intervention, participants will be encouraged to maintain their home exercise program. Participants will be randomized to 1 of 2 types of education (pain education or pathoanatomic), in addition to exercise. Pain education will focus on the biological and psychological mechanisms of pain within a biopsychosocial framing of AT. Pathoanatomic education will focus on biological processes within a more traditional biomedical framework of AT. Evaluation sessions will be completed at baseline and 8-week follow-up, and self-reported outcome measures will be completed at the 12-week follow-up. Both groups will complete progressive Achilles loading exercises in 4 phases throughout the 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. Primary outcomes are movement-evoked pain during heel raises and self-reported function (patient-reported outcome measure information system-Physical Function). Secondary outcomes assess central nervous system nociceptive processing, psychological factors, motor function, and feasibility., Results: Institutional review board approval was obtained on April 15, 2019, and study funding began in July 2019. As of March 2020, we randomized 23 out of 66 participants. In September 2020, we screened 267 individuals, consented 68 participants, and randomized 51 participants. We anticipate completing the primary data analysis by March 2022., Conclusions: The TEAch study will evaluate the utility of pain education for those with AT and the effects of improved patient knowledge on pain, physical function, and clinical outcomes., International Registered Report Identifier (irrid): DERR1-10.2196/19111., (©Andrew A Post, Ebonie K Rio, Kathleen A Sluka, G Lorimer Moseley, Emine O Bayman, Mederic M Hall, Cesar de Cesar Netto, Jason M Wilken, Jessica F Danielson, Ruth Chimenti. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 03.11.2020.)

The utility of ultrasound in sports medicine is improving the sports medicine physician's ability to rapidly diagnose and treat a multitude of sports related pathologies. In this article, we clearly outline the current status of the evidence in support of using sports ultrasound in the setting of acute abdominal and thoracic trauma, acute lung illness, limited cardiac evaluation of a collapsed athlete, volume status assessment, and fracture evaluation.

"Hands-on" teaching is an important part of sports ultrasound (US) education in sports medicine fellowships. However, physical distancing requirements during a global pandemic have resulted in cancellation and/or postponement of "in-person" educational sessions, ultrasound conferences, and clinical diagnostic and interventional ultrasound cases that enhance ultrasound training. For "hands-on" sports ultrasound teaching to continue during these uncertain times, the educational model must be adapted. The use of virtual meeting platforms to display ultrasound images is possible, and this not only allows for instructor demonstration but also gives the instructor an opportunity to observe the learner scanning and provide direct feedback in real-time. Moving forward, virtual ultrasound teaching methods will likely continue to be of educational value, as they provide increased access to individualized instruction from skilled instructors and eliminate travel time and cost of conferences and instructional sessions.

Objectives: Peripherally directed treatments (targeted exercise, surgery) can reduce, but not fully eliminate, pain for up to 40% of patients with Achilles tendinopathy. The objectives of the present study were (1) to identify indicators of altered central processing in participants with Achilles tendinopathy compared to controls, and (2) to determine which indicators of altered central processing would persist after a local anesthetic injection in patients with Achilles tendinopathy., Design: Mechanistic clinical trial., Methods: Forty-six adults (23 with chronic Achilles tendinopathy, 23 matched controls) repeated (1) a movement-evoked pain rating, (2) motor performance assessment, (3) pain psychology questionnaires, and (4) quantitative sensory testing. Participants with Achilles tendinopathy received a local anesthetic injection before repeat testing and controls did not. Mixed-effects analyses of variance examined the effects of group, time, and group by time., Results: The Achilles tendinopathy group had movement-evoked pain, motor dysfunction, and higher pain psychological factors (pain catastrophizing, kinesiophobia) compared to controls ( P <.05). The Achilles tendinopathy group did not have indicators of nociplastic pain with quantitative sensory testing ( P >.05). In those with Achilles tendinopathy, local anesthetic injection eliminated pain and normalized the observed deficits in heel-raise performance and pain catastrophizing (group-by-time effect, P <.01), but not in kinesiophobia ( P = .45). Injection did not affect measures of nociplastic pain ( P >.05)., Conclusion: People with Achilles tendinopathy had elevated pain psychological factors and motor dysfunction but no signs of nociplastic pain with quantitative sensory testing. Removal of nociceptive input normalized movement-evoked pain and some indicators of altered central processing (motor dysfunction, pain catastrophizing), but not kinesiophobia. J Orthop Sports Phys Ther 2020;50(6):334-343. Epub 29 Apr 2020. doi:10.2519/jospt.2020.9242 .

The Standardized Video Interview (SVI) was developed by the Association of American Medical Colleges to assess professionalism, communication, and interpersonal skills of residency applicants. How SVI scores compare with other measures of these competencies is unknown. The goal of this study was to determine whether there is a correlation between the SVI score and both faculty and patient ratings of these competencies in emergency medicine (EM) applicants. This was a retrospective analysis of a prospectively collected dataset of medical students. Students enrolled in the fourth-year EM clerkship at our institution and who applied to the EM residency Match were included. We collected faculty ratings of the students' professionalism and patient care/communication abilities as well as patient ratings using the Communication Assessment Tool (CAT) from the clerkship evaluation forms. Following completion of the clerkship, students applying to EM were asked to voluntarily provide their SVI score to the study authors for research purposes. We compared SVI scores with the students' faculty and patient scores using Spearman's rank correlation. Of the 43 students from the EM clerkship who applied in EM during the 2017-2018 and 2018-2019 application cycles, 36 provided their SVI scores. All 36 had faculty evaluations and 32 had CAT scores available. We found that SVI scores did not correlate with faculty ratings of professionalism (rho = 0.09, p = 0.13), faculty assessment of patient care/communication (rho = 0.12, p = 0.04), or CAT scores (rho = 0.11, p = 0.06). Further studies are needed to validate the SVI and determine whether it is indeed a predictor of these competencies in residency.

Introduction: Despite the extraordinary amount of time physicians spend communicating with patients, dedicated education strategies on this topic are lacking. The objective of this study was to develop a multimodal curriculum including direct patient feedback and assess whether it improves communication skills as measured by the Communication Assessment Tool (CAT) in fourth-year medical students during an emergency medicine (EM) clerkship., Methods: This was a prospective, randomized trial of fourth-year students in an EM clerkship at an academic medical center from 2016-2017. We developed a multimodal curriculum to teach communication skills consisting of 1) an asynchronous video on communication skills, and 2) direct patient feedback from the CAT, a 15-question tool with validity evidence in the emergency department setting. The intervention group received the curriculum at the clerkship midpoint. The control group received the curriculum at the clerkship's end. We calculated proportions and odds ratios (OR) of students achieving maximum CAT score in the first and second half of the clerkship., Results: A total of 64 students were enrolled: 37 in the control group and 27 in the intervention group. The percentage of students achieving the maximum CAT score was similar between groups during the first half (OR 0.70, p = 0.15). Following the intervention, students in the intervention group achieved a maximum score more often than the control group (OR 1.65, p = 0.008)., Conclusion: Students exposed to the curriculum early had higher patient ratings on communication compared to the control group. A multimodal curriculum involving direct patient feedback may be an effective means of teaching communication skills.

Background: Tendinopathy is a common cause of elbow pain in the active population. Ultrasound-guided tenotomy (USGT) is a minimally invasive treatment option for cases recalcitrant to conservative management. Several case studies have shown promising preliminary results of USGT for common extensor tendinopathy and common flexor tendinopathy, but none have included USGT for triceps tendinopathy. This larger retrospective study evaluates the effectiveness and safety of USGT for all elbow tendinopathy sites at short- and long-term follow-up., Methods: Retrospective chart review identified 131 patients (144 procedures; mean age ± standard deviation [SD], 48.1 ± 9.8 years; mean body mass index ± SD, 32.2 ± 7.7; 59% male) with elbow tendinopathy (104 common extensor tendinopathy, 19 common flexor tendinopathy, 8 triceps tendinopathy) treated with USGT over a 6-year period by a single physician. Pain and quality-of-life measures were collected at baseline. Pain, quality-of-life, satisfaction with outcome, and complications were collected at short-term (2-, 6-, and 12-week) and long-term (median 2.7 years, interquartile range = 2.0-4.0 years) follow-up., Results: Overall, USGT for elbow tendinopathy decreased pain from moderate/severe at baseline to mild/occasional at short- and long-term follow-up (P < .01). Quality-of-life assessments showed significant improvement in physical function at short- and long-term follow-up (P < .01). The majority (70%) of patients were satisfied with the procedure. There was a 0% complication rate., Conclusion: Benefits of USGT include pain relief, improved physical function, and high patient satisfaction. USGT is a safe, minimally invasive treatment for refractory elbow tendinopathy., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Due to the novelty of percutaneous ultrasonic tenotomy, the risks and benefits of this minimally invasive procedure for insertional Achilles tendinopathy pain have only been examined in case studies and retrospective chart reviews for other diagnoses. This retrospective chart review over a 3.5-year period identified 34 patients with insertional Achilles tendinopathy who had percutaneous ultrasonic tenotomy (mean age ± SD, 52.2 ± 11.6 years; mean body mass index, 32.9 ± 7.5 kg/m 2 ; 62% female). This procedure reduced the rate of moderate/severe pain from 68% at baseline to 15% at the long-term follow-up and had a satisfaction rate of 70%. There was 1 minor complication out of 40 procedures in 34 patients., (© 2018 by the American Institute of Ultrasound in Medicine.)

Return to play after thigh muscle strain injury is difficult to predict and recurrent injury rates are high. There is currently no agreement on the optimal return to play protocol following muscle injury and utility of imaging is debated. Ultrasound has become an increasingly utilized imaging modality and offers several potential advantages for monitoring the return to play process following muscle injury. An ultrasound scanning protocol is presented which provides real-time guidance on muscle healing and may assist with identification of those athletes at risk of reinjury who otherwise appear clinically fit for return to play.

A bioactive glass series (0.42SiO 2 -0.10Na 2 O-0.08CaO-(0.40 - x)ZnO-(x)Ga 2 O 3 ) was synthesized, and it is efficacy against the Gram (-ve) bacteria Escherichia coli (E. coli), the Gram (+ve) bacteria Staphylococcus aureus (S. aureus), and the fungus Candida albicans (C. albicans), were characterized through liquid broth analysis. The glass series was also seeded in CMC-Dex hydrogels at three different loadings (0.05, 0.10, and 0.25 m 2 ), and the antibacterial and antifungal efficacies of the resulting composites were characterized using both liquid broth and agar diffusion analysis. Liquid broth analysis was conducted using liquid extracts, which for glass samples were obtained after incubation for up to 30 days in both ultrapure water and phosphate buffered saline (PBS), while glass-hydrogel extracts were obtained solely in PBS. Glass extracts (water) decreased C. albicans viability, while those obtained in PBS decreased the viability of both E. coli and C. albicans. Glass-hydrogel extracts exhibited slight inhibition of E. coli and C. albicans. However, none of the liquid extracts decreased S. aureus viability. Glass-hydrogel composites produced inhibition zones in all three microbial cultures, with the greatest efficacy against C. albicans. The results of this study suggest these materials have potential as bone void-filling materials which display antifungal, and possibly, antibacterial properties. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1102-1113, 2017., (© 2016 Wiley Periodicals, Inc.)

Introduction: Chest pain is a common emergency department (ED) presentation accounting for 8-10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level., Methods: We conducted a single-institution retrospective observational study of ED patients with a diagnosis of chest pain as determined by diagnostic code from our hospital administrative database. We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram (ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into two groups: "admission" (this included observation and inpatients) and "discharged." We stratified physicians by age, gender, residency location, and years since medical school. We controlled for patient- and hospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values., Results: Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to the hospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) were discharged. Median number of patients per physician was 132 (interquartile range 89-172). Average admission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) were to observation. There was significant variation in the admission rate at the individual physician level with adjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians' characteristics, years elapsed since finishing medical school demonstrated a trend towards association with a higher admission probability., Conclusion: There is substantial variation among physicians in the management of patients presenting with chest pain, with physician experience playing a role., 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: Medical student grades during emergency medicine (EM) rotations are a key factor in resident selection. The variability in grading among EM clerkships is not well understood., Objective: The objective was to describe the current grade distribution of fourth-year EM clerkships., Methods: This was an observational study at an EM residency program. We identified grade distributions by reviewing the standard letter of evaluation from individuals applying to our residency program for the 2016 match. Descriptive statistics of proportions, standard deviations (SDs), and p-values were calculated., Results: A total of 1,075 applications from 236 individual clerkships were reviewed. Thirty-four programs did not give an honors grade during the previous year. Four of these programs distributed a highest grade of "high pass" and 30 gave only "pass" and/or "fail." Of the remaining 202 programs, the percentage of grades that were given as honors ranged from 1% to 87% with a mean (±SD) of 25% (±17.2%). Of the 202 programs that granted honors grades, 63 (31.2%) sites gave between 1 and 14.9% honors grades, 69 (34.2%) gave 15% to 29.9% honors grades, 27 (13.4%) gave 30% to 44.9% honors grades, and 24 (11.9%) programs granted honors to greater than 45% of their students. Medical schools required an EM rotation at 82 (40.6%) sites. Among these programs, honors grades were given to 24% (±16.7%) of students with a range of 4% to 85% while programs that did not require clerkships gave a mean (±SD) of 26% (±17.5%) with a range of 1% to 87% and a p-value of 0.54., Conclusions: Honor grade distribution varies markedly across U.S. fourth-year EM clerkship sites. Requiring EM clerkships does not affect honor percentages. A minority of sites only give pass/fail grades. Program directors should consider this marked variation in grades when reviewing EM residency applications.

A bioactive glass series (0.42SiO2-0.10Na2O-0.08CaO-(0.40-X)ZnO-(X)Ga2O3) was incorporated into carboxymethyl cellulose (CMC)/dextran (Dex) hydrogels in three different amounts (0.05, 0.10, and 0.25m(2)), and the resulting composites were characterized using transmission electron microscopy (TEM), differential scanning calorimetry (DSC), and (13)C Cross Polarization Magic Angle Spinning Nuclear Magnetic Resonance (CP MAS-NMR). Composite extracts were also evaluated in vitro against MG-63 osteosarcoma cells. TEM confirmed glass distribution throughout the composites, although some particle agglomeration was observed. DSC revealed that glass composition and content did have small effects on both Tg and Tm. MAS-NMR revealed that both CMC and Dex were successfully functionalized, that cross-linking occurred, and that glass addition did slightly alter bonding environments. Cell viability analysis suggested that extracts of the glass and composites with the largest Ga-content significantly decreased MG-63 osteosarcoma viability after 30days. This study successfully characterized this composite series, and demonstrated their potential for anti-cancerous applications., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: The importance of meniscal preservation has become widely accepted, and meniscal repair techniques have evolved over recent years. With new techniques come new complications, which are critical to recognize., Purpose: To describe a new complication of foreign body reaction from a nonabsorbable suture anchor associated with improper placement of the all-inside meniscal device., Study Design: Case series; Level of evidence, 4., Methods: This study was a retrospective review of 3 patients who developed pain associated with a foreign body reaction from a misplaced all-inside meniscal device., Results: All patients had a delayed diagnosis (6 months to 8 years) and negative magnetic resonance imaging (MRI). Diagnostic ultrasound identified the misplaced suture with foreign body reaction and was used to guide a diagnostic injection of local anesthetic prior to surgical intervention. Intraoperative ultrasound guidance was utilized to precisely localize and excise the suture material and associated reactive tissue., Conclusion: Foreign body reaction from a misplaced all-inside meniscal device is a previously unreported complication. Diagnosis is challenging as MRI and arthroscopy can be unrevealing. Diagnostic ultrasound was able to identify the foreign body reaction, confirm the diagnosis by facilitating diagnostic local anesthetic injection, and guide surgical excision. Sonographic evaluation should be considered in patients presenting with ongoing knee pain after all-inside meniscus repair., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

Chronic and acute shoulder pain and dysfunction are common complaints among patients. Shoulder pain may be the result of abnormality involving the rotator cuff, subacromial-subdeltoid bursa, biceps tendon, glenoid labrum, glenohumeral joint, acromioclavicular joint, sternoclavicular joint, or glenohumeral joint capsule. Ultrasound-guided (USG) procedures of the shoulder are well established for interventional management. Ultrasound provides the advantages of excellent soft tissue resolution, injection accuracy, low cost, accessibility, portability, lack of ionizing radiation, and the ability to perform real-time image-guided procedures. The purpose of this article is to review common indications and effective techniques for USG injections about the shoulder., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Chronic patellar tendinopathy is a common complaint among athletes who repetitively stress the extensor mechanism of the knee. Multiple treatment options have been described, but evidence is lacking, specifically when eccentric loading has failed. Debate continues regarding the patho-etiology of chronic patellar tendon pain. There has been recent interest regarding the neurogenic influences involved in chronic tendinopathy, and interventions targeting neovessels and accompanying neonerves have shown promise. This is the first description of an ultrasound-guided technique in which the neovessels and accompanying neonerves in patellar tendinopathy were targeted using a needle scraping technique of the posterior surface of the patellar tendon., (Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Although nonoperative treatment options for chronic exertional compartment syndrome (CECS) are often used in clinical practice, supporting evidence is limited. The objective of this study was to systematically review the literature for nonsurgical treatment options for CECS of the lower leg. The literature search identified seven articles describing in total four different treatment options: massage, gait changes, chemodenervation, and ultrasound-guided (USG) fascial fenestration. Pertinent studies were in the form of case series and one case report, which limited the robustness of the data. Nevertheless, all four treatment options have little to no reported adverse effect profiles and can be considered in clinical practice. In addition, gait changes and USG fascial fenestration were found to have continued effect at 1 and 1.5 years, respectively.

Lactic acid has played an important role in the traditional theory of muscle fatigue and limitation of endurance exercise performance. It has been called a waste product of anaerobic metabolism and has been believed to be responsible for the uncomfortable "burn" of intense exercise and directly responsible for the metabolic acidosis of exercise, leading to decreased muscle contractility and ultimately cessation of exercise. Although this premise has been commonly taught, it is not supported by the scientific literature and has led to a great deal of confusion among the sports medicine and exercise science communities. This review will provide the sports medicine clinician with an understanding of contemporary lactate theories, including lactate's role in energy production, its contributions to metabolic acidosis, and its function as an energy substrate for a variety of tissues. Lactate threshold concepts will also be discussed, including a practical approach to understanding prediction of performance and monitoring of training progress based on these parameters., (Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Tenosynovial (extra-articular) chondromatosis (TC) is a condition characterized by the cartilaginous proliferation of synovial cells derived from the synovial lining of bursa and tendon sheaths. These lesions are often multinodular and most commonly present with complaints of swelling or pain. Treatment of TC primarily entails surgical excision. There are no known reports of TC in collegiate athletes. We present a case of TC in a Division I tennis player.

Plantar fasciopathy is a painful, degenerative condition of the plantar fascia that affects 2 million people annually and has an estimated 10% lifetime prevalence. When both nonoperative and operative management fails, patients have limited therapeutic options. We present a case of an active 47-year-old male runner who was successfully treated with songraphically guided percutaneous ultrasonic fasciotomy after undergoing a prolonged course of nonoperative management and an endoscopic plantar fascia release procedure. Percutaneous ultrasonic fasciotomy may be considered in patients with chronic, refractory plantar fasciopathy, including those for whom a prior operative release procedure has failed., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)