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This article was migrated. The article was marked as recommended. Introduction: Emergency medicine milestones suggest skill performance expectations for graduating medical students. The objective of this study is to examine differences between student's perceived proficiency and faculty expectations relative to Level 1 EM milestones, identifying opportunities for curriculum development. Methods: Using ACGME milestone language, the authors developed a survey that measures student perceived skill proficiency with 22 skills, which was administered to fourth year medical students at 6 institutions. Similar surveys were sent to faculty to determine their expectations of students' skill proficiency. Differences between student and faculty responses were calculated. Results: There were 608 student and 114 faculty responses. There was a statistically significant difference between mean student and faculty responses for 13 of the 22 skills. For 10 of these skills, students rated their own skill proficiency higher than faculty expectations. For 3 of the skills, faculty rated their expectations higher than students' perceived proficiency. Conclusions: For pharmacology skills, student ratings were low, indicating an area to focus curriculum development. Items where student ratings are higher than faculty may be a result of overconfidence or a lack of understanding by faculty of students' abilities. Formal assessment of skills in these areas would help clarify the reason and direct faculty and curriculum development., (Copyright: © 2018 Pettit K et al.)

The crosstalk between NK cells and M1 macrophages has a vital role in the protection against infections and tumor development. However, macrophages in the tumor resemble an M2 phenotype, and, at present, their effect on NK cells is less clear. This study investigated whether tumor-associated macrophages (TAMs) have a role in altering NK cell function and phenotype using in vitro cocultures of murine NK cells with peritoneal or bone marrow-derived, M2-polarized macrophages or TAMs isolated from spontaneous mouse breast tumors. We report here that both peritoneal and bone marrow-derived M2 macrophages, as well as TAMs, substantially inhibit NK cell activation and concordant cytotoxicity against tumor cells. The mechanism for this inhibition was found to require contact between the respective cell types. Both M2 macrophages and TAMs are producers of the immunosuppressive cytokine TGF-β. The inhibition of TGF-β restored the cytotoxicity of NK cells in contact with M2 macrophages, implicating TGF-β in the mechanism for NK cell inhibition. In addition to affecting NK cell function, TAMs also induced a CD27 low CD11b high -exhausted NK cell phenotype, which corresponds with the reduced activation and cytotoxicity observed. This study reveals a novel implication of TAMs in the tumor-associated inhibition of NK cell function by demonstrating their capacity to directly alter NK cell cytotoxicity and phenotype in a contact-dependent mechanism involving TGF-β. These findings identify the interaction between NK cells and TAMs as a prospective therapeutic target to enhance NK cell effector function for effective NK cell cancer therapies., (© Society for Leukocyte Biology.)

Introduction: In April 2013, the National Board of Medical Examiners (NBME) released an Advanced Clinical Examination (ACE) in emergency medicine (EM). In addition to this new resource, CDEM (Clerkship Directors in EM) provides two online, high-quality, internally validated examinations. National usage statistics are available for all three examinations, however, it is currently unknown how students entering an EM residency perform as compared to the entire national cohort. This information may help educators interpret examination scores of both EM-bound and non-EM-bound students., Objectives: The objective of this study was to compare EM clerkship examination performance between students who matched into an EM residency in 2014 to students who did not. We made comparisons were made using the EM-ACE and both versions of the National fourth year medical student (M4) EM examinations., Method: In this retrospective multi-institutional cohort study, the EM-ACE and either Version 1 (V1) or 2 (V2) of the National EM M4 examination was given to students taking a fourth-year EM rotation at five institutions between April 2013 to February 2014. We collected examination performance, including the scaled EM-ACE score, and percent correct on the EM M4 exams, and 2014 NRMP Match status. Student t-tests were performed on the examination averages of students who matched in EM as compared with those who did not., Results: A total of 606 students from five different institutions took both the EM-ACE and one of the EM M4 exams; 94 (15.5%) students matched in EM in the 2014 Match. The mean score for EM-bound students on the EM-ACE, V1 and V2 of the EM M4 exams were 70.9 (n=47, SD=9.0), 84.4 (n=36, SD=5.2), and 83.3 (n=11, SD=6.9), respectively. Mean scores for non-EM-bound students were 68.0 (n=256, SD=9.7), 82.9 (n=243, SD=6.5), and 74.5 (n=13, SD=5.9). There was a significant difference in mean scores in EM-bound and non-EM-bound student for the EM-ACE (p=0.05) and V2 (p<0.01) but not V1 (p=0.18) of the National EM M4 examination., Conclusion: Students who successfully matched in EM performed better on all three exams at the end of their EM clerkship.

Introduction: There is great variation in the knowledge base of Emergency Medicine (EM) interns in July. The first objective knowledge assessment during residency does not occur until eight months later, in February, when the American Board of EM (ABEM) administers the in-training examination (ITE). In 2013, the National Board of Medical Examiners (NBME) released the EM Advanced Clinical Examination (EM-ACE), an assessment intended for fourth-year medical students. Administration of the EM-ACE to interns at the start of residency may provide an earlier opportunity to assess the new EM residents' knowledge base. The primary objective of this study was to determine the correlation of the NBME EM-ACE, given early in residency, with the EM ITE. Secondary objectives included determination of the correlation of the United States Medical Licensing Examination (USMLE) Step 1 or 2 scores with early intern EM-ACE and ITE scores and the effect, if any, of clinical EM experience on examination correlation., Methods: This was a multi-institutional, observational study. Entering EM interns at six residencies took the EM-ACE in July 2013 and the ABEM ITE in February 2014. We collected scores for the EM-ACE and ITE, age, gender, weeks of clinical EM experience in residency prior to the ITE, and USMLE Step 1 and 2 scores. Pearson's correlation and linear regression were performed., Results: Sixty-two interns took the EM-ACE and the ITE. The Pearson's correlation coefficient between the ITE and the EM-ACE was 0.62. R-squared was 0.5 (adjusted 0.4). The coefficient of determination was 0.41 (95% CI [0.3-0.8]). For every increase of one in the scaled EM-ACE score, we observed a 0.4% increase in the EM in-training score. In a linear regression model using all available variables (EM-ACE, gender, age, clinical exposure to EM, and USMLE Step 1 and Step 2 scores), only the EM-ACE score was significantly associated with the ITE (p<0.05). We observed significant colinearity among the EM-ACE, ITE and USMLE scores. Gender, age and number of weeks of EM prior to the ITE had no effect on the relationship between EM-ACE and the ITE., Conclusion: Given early during intern year, the EM-ACE score showed positive correlation with ITE. Clinical EM experience prior to the in-training exam did not affect the correlation.

Background: Core content in Emergency Medicine Residency Programs is traditionally covered in didactic sessions, despite evidence suggesting that learners do not retain a significant portion of what is taught during lectures., Discussion: We describe techniques that medical educators can use when leading teaching sessions to foster engagement and encourage self-directed learning, based on current literature and evidence about learning., Conclusions: When these techniques are incorporated, sessions can be effective in delivering core knowledge, contextualizing content, and explaining difficult concepts, leading to increased learning., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Since 2011 two online, validated exams for fourth-year emergency medicine (EM) students have been available (National EM M4 Exams). In 2013 the National Board of Medical Examiners offered the Advanced Clinical Examination in Emergency Medicine (EM-ACE). All of these exams are now in widespread use; however, there are no data on how they correlate. This study evaluated the correlation between the EM-ACE exam and the National EM M4 Exams., Methods: From May 2013 to April 2014 the EM-ACE and one version of the EM M4 exam were administered sequentially to fourth-year EM students at five U.S. medical schools. Data collected included institution, gross and scaled scores and version of the EM M4 exam. We performed Pearson's correlation and random effects linear regression., Results: 305 students took the EM-ACE and versions 1 (V1) or 2 (V2) of the EM M4 exams (281 and 24, respectively) [corrected].The mean percent correct for the exams were as follows: EM-ACE 74.9 (SD-9.82), V1 83.0 (SD-6.39), V2 78.5 (SD-7.70) [corrected]. Pearson's correlation coefficient for the V1/EM-ACE was 0.53 (0.43 scaled) and for the V2/EM-ACE was 0.58 (0.41 scaled) [corrected]. The coefficient of determination for V1/ EM-ACE was 0.73 and for V2/EM-ACE 0.71 (0.65 and .49 for scaled scores) [ERRATUM]. The R-squared values were 0.28 and 0.30 (0.18 and 0.13 scaled), respectively [corrected]. There was significant cluster effect by institution., Conclusion: There was moderate positive correlation of student scores on the EM-ACE exam and the National EM M4 Exams.

The influence of sex and gender on patient care is just being recognized in emergency medicine (EM). Providers are realizing the need to improve outcomes for both men and women by incorporating sex- and gender-specific science into clinical practice, while EM researchers are now beginning to study novel sex- and gender-specific perspectives in the areas of acute care research. This article serves as an update on the sex differences in a variety of acute clinical care topics within the field of EM and showcases opportunities for improving patient care outcomes and expanding research to advance the science of gender-specific emergency care., (© 2013 by the Society for Academic Emergency Medicine.)

Background: As most genital chlamydia infections are asymptomatic, screening is the main way to detect and cases for treatment. We undertook a systematic review of studies assessing the efficacy of interventions for increasing the uptake of chlamydia screening in primary care., Methods: We reviewed studies which compared chlamydia screening in the presence and the absence of an intervention. The primary endpoints were screening rate or total tests., Results: We identified 16 intervention strategies; 11 were randomised controlled trials and five observational studies, 10 targeted females only, five both males and females, and one males only. Of the 15 interventions among females, six were associated with significant increases in screening rates at the 0.05 level including a multifaceted quality improvement program that involved provision of a urine jar to patients at registration (44% in intervention clinics vs. 16% in the control clinic); linking screening to routine Pap smears (6.9% vs. 4.5%), computer alerts for doctors (12.2% vs. 10.6%); education workshops for clinic staff; internet-based continuing medical education (15.5% vs. 12.4%); and free sexual health consultations (16.8% vs. 13.2%). Of the six interventions targeting males, two found significant increases including the multifaceted quality improvement program in which urine jars were provided to patients at registration (45% vs. 15%); and the offering by doctors of a test to all presenting young male clients, prior to consultation (29 vs. 4%)., Conclusions: Interventions that promoted the universal offer of a chlamydia test in young people had the greatest impact on increasing screening in primary care.

A multilocus sequence typing (MLST) scheme has been developed for Enterococcus faecium. Internal fragments from seven housekeeping genes of 123 epidemiologically unlinked isolates from humans and livestock and 16 human-derived isolates from several outbreaks in the United States, the United Kingdom, Australia, and The Netherlands were analyzed. A total of 62 sequence types were detected in vancomycin-sensitive E. faecium (VSEF) and vancomycin-resistant E. faecium (VREF) isolates. VSEF isolates were genetically more diverse than VREF isolates. Both VSEF and VREF isolates clustered in host-specific lineages that were similar to the host-specific clustering obtained by amplified fragment length polymorphism analysis. Outbreak isolates from hospitalized humans clustered in a subgroup that was defined by the presence of a unique allele from the housekeeping gene purK and the surface protein gene esp. The MLST results suggest that epidemic lineages of E. faecium emerged recently worldwide, while genetic variation in both VREF and VSEF was created by longer-term recombination. The results show that MLST of E. faecium provides an excellent tool for isolate characterization and long-term epidemiologic analysis.