As a key component of scientific research, hypothesis testing incorporates a null hypothesis (H₀) of no difference in a larger population and an alternative hypothesis (H₁or H_A) that becomes true when the null hypothesis is shown to be false. Two potential types of statistical error are Type I error (α, or level of significance), when one falsely rejects a null hypothesis that is true, and Type II error (β), when one fails to reject a null hypothesis that is false. To reduce Type I error, one should decrease the pre-determined level of statistical significance. To decrease Type II error, one should increase the sample size in order to detect an effect size of interest with adequate statistical power. Reducing Type I error tends to increase Type II error, and vice versa. Type III error, although rare, occurs when one correctly rejects the null hypothesis of no difference, but does so for the wrong reason. The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge.

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Background: Internationally, emergency medicine (EM) physicians are vulnerable to both physical and verbal violence. Few studies have examined or compared perceptions and the impacts of workplace violence in India and the United States (US). Objectives: To assess the perceived incidence of workplace violence and its implications on sleep, missed days of work, fear in the workplace, and overall job satisfaction. Materials and Methods: This was an anonymous, prospective, cross-sectional electronic survey of EM residents and physicians. A cohort of physicians in the US was matched to a cohort of physicians in India. Results: Overall, 286 physicians were eligible to participate, 177 responded (98 people from the US and 79 from Indian, for a 62% total response rate). In the US 100% of respondents witnessed verbal violence, whereas only 23% of verbal abuse cases were reported. In India, 89% of respondents witnessed verbal abuse, 46% of cases were reported. Respondents in the US both witnessed and experienced significantly more verbal and physical abuse (P < 0.001). Despite the differences in perceived rates of violence, there were no significant differences between country cohorts regarding the consequences of these incidents. This includes self-reported sleep, missed days of work, and fear of going to the workplace. US respondents were less satisfied with their jobs due to workplace violence as compared to their Indian colleagues (P = 0.041). Conclusion: ED workplace violence is common internationally, underreported, and results in poor job satisfaction, workplace fear, and loss of sleep. The following core competencies are addressed in this article: Patient care, Professionalism, Systems-based practice.

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Gitelman syndrome (GS) is an autosomal recessive tubular disorder with an incidence of 1 in 40,000. It is characterized by hypokalemia, hypomagnesemia, metabolic alkalosis, with secondary hyperreninemia, which can easily be managed with a potassium (K⁺) sparing diuretic if correctly recognized, and with an understanding of the pathophysiology. A 17-year-old male patient presented to the emergency department after an episode of tonic-clonic seizure activity and subsequent loss of consciousness. Diagnosis of GS was made following persistent hypokalemia despite adequate repletion and further laboratory analysis. The patient was placed on a K⁺-sparing diuretic and had no further seizure activity. This case illustrates the importance of proper clinical and diagnostic evaluation of electrolyte abnormalities in all patients, especially in younger patients in whom early diagnosis can be crucial in preventing future complications. The following core competencies are addressed in this article: Medical knowledge, Patient care.

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Paraneoplastic limbic encephalitis is a neurological syndrome characterized by seizures, rapidly progressive short-term memory loss and psychiatric symptoms. It may present in association with cancer, infection, or as an isolate clinical condition. Definite diagnosis requires either cerebrospinal fluid analysis or neuroimaging evidence of the involvement of the limbic system besides the clinical features. Here, we present the imaging features of limbic encephalitis. The following core competencies are addressed in this article: Medical knowledge, Patient care.

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Context and Aims: Primary objective of this study was to estimate time to infection after extracorporeal membrane oxygenation (ECMO) initiation among patients who received prophylactic antibiotics compared to those who did not. Subjects and Methods: This retrospective cohort study included adult patients initiated on ECMO between February 1, 2009, and June 30, 2012, in Intensive Care Units at an 816-bed tertiary care hospital. Results: Prophylaxis defined as an antibiotic initiated at start of ECMO without other bacterial infectious indications was categorized into three levels: (1) No prophylaxis, (2) single antibiotic, and (3) combination two or more antibiotics with activity against methicillin-resistant Staphylococcus aureus and Gram-negative bacteria. Of the 96 patients included, 37 (39%) patients acquired a sterile site infection; 17 of which were caused by of multidrug-resistant organisms. There was no significant difference in the proportion of new infections by antibiotic exposure group. By 500 h on ECMO, all patients had a 60% probability of developing infection. There was a trend that patients on combination antibiotics were less likely to develop a sterile site infection than patients who were not exposed to antibiotics after adjusting for age and comorbid illnesses (adjusted hazard ratio 0.44, 95% confidence interval 0.17–1.13) (P = 0.09). Conclusions: Patients on ECMO on single and combination antibiotic regimens demonstrated no significant difference in the hazard for the development of a new sterile site infection compared to no antibiotic group. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice.

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Background: Emergency medicine (EM) as a specialty in India is at its infancy. Point-of-care ultrasound (POCUS) is an indispensable tool for the emergency physician (EP). We sought to determine the current experience and resources of POCUS training among EM teaching programs in India. Methods: At a national EM board review course, a survey was carried out among 41 residents from 15 different teaching institutes across seven states of India. The survey consisted of questions pertaining to their experience and knowledge in performing basic and advanced POCUS examinations and its utilization in their department. Results: Most residents (90.2%) were of the opinion that POCUS is an indispensable tool for the EP. All residents had access to an ultrasound (US) machine, with 90.2% having at least one dedicated machine in their department. 12.1% of the residents utilized POCUS less than five times a day while 14.6% reported using US more than twenty times a day. 68.5% of residents identified the major modality of learning POCUS was from a mentor, and about one-third were exclusively dependent on it. The least utilized sources were books and lectures (19%). Extended focused assessment with sonography in trauma (EFAST) was the most frequently performed examination (95%) and was performed with highest level of confidence. Among the advanced examinations, residents knew how to perform and interpret airway (53.7%) and renal sonography (53.7%) the most while they were least familiar with ocular sonography (19%). 70.1% residents reported that POCUS was utilized for facilitating vascular access, 53.7% for nerve blocks, and paracentesis around 19%. Only 46% reported that other departments rely on their findings to make clinical decisions. Conclusion: POCUS was utilized by the residents for different diagnostic examinations and interventions, with the most common being EFAST. The most common learning source of POCUS was from hands-on training by a mentor. There exists a need for guidelines or standardization of POCUS in the EM curriculum to achieve resident competency. The following core competencies are addressed in this article: Interpersonal skills and communication, Medical knowledge, Patient care, Systems-based practice.

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The Academic International Medicine (AIM) Congress (the Congress) is the official meeting of the American College of Academic International Medicine, a United States organization dedicated specifically to connecting academic physicians from diverse areas of expertise toward the common goals of sustainable global medical outreach and multinational clinical research and education. The organization's main focus is to promote AIM and to establish a platform for individuals, academic institutions, and a broad range of organizations to collaborate and work collectively to create a foundation for efficient and sustainable resource sharing. World-renowned experts and speakers from the AIM community attended and participated in the 2017 Congress held in Clearwater Beach, Florida, from July 28 to July 30, 2017. This year's Congress also included the participation of the Global Association of Physicians of Indian Origin, the American Association of Physicians of Indian Origin, and the OPUS 12 Foundation, Inc. Finally, the Congress featured the inaugural Annual Scientific Forum as a platform for exchanging scientific knowledge among academic experts. This report presents an overview of this major academic event, including the full listing of podium presentations from the 2017 Scientific Forum. The following core competencies are addressed in this article: Practice-based learning and improvement, Systems-based practice, Interpersonal and communication skills, Professionalism.

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Small bowel obstruction is a commonly encountered surgical diagnosis, most frequently attributed to hernias, adhesions, or malignancy. Intra-abdominal fibromatoses are rare tumors with heterogeneous clinical manifestations. Infrequently, acute presentation of bowel obstruction may be associated with intra-abdominal fibromatosis – also referred to as “desmoid tumor” – a benign proliferation of myofibroblasts which most often arise from the mesentery or retroperitoneum and are nonmalignant in character. Here, we describe a case of an isolated abdominal fibromatosis with primary involvement of the intestinal wall and the clinical presentation of bowel obstruction. The patient was managed by surgical resection and had complete recovery. As demonstrated in the current case, physically small, relatively isolated desmoid tumors have the potential to significantly impact the patient. Individualized treatment approaches produce good clinical outcomes in most cases. The following core competencies are addressed in this article: Medical knowledge, Patient care.

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The American College of Academic International Medicine (ACAIM) represents a group of clinicians who seek to promote clinical, educational, and scientific collaboration in the area of Academic International Medicine (AIM) to address health care disparities and improve patient care and outcomes globally. Significant health care delivery and quality gaps persist between high-income countries (HICs) and low-and-middle-income countries (LMICs). International Medical Programs (IMPs) are an important mechanism for addressing these inequalities. IMPs are international partnerships that primarily use education and training-based interventions to build sustainable clinical capacity. Within this overall context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs navigate the development of IMPs. The aim of this consensus statement is to highlight best practices and engage the global community in ACAIM's mission. Through this work, we highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful and ethical development; (3) information technology; (4) medical education and training; (5) research and scientific investigation; and (6) program durability. The ultimate goal of current initiatives is to create a foundation upon which ACAIM and other organizations can begin to formalize a truly global network of clinical education/training and care delivery sites, with long-term sustainability as the primary pillar of international inter-institutional collaborations. The following core competencies are addressed in this article: Patient care, Medical knowledge, Professionalism, Interpersonal and communication skills, Practice-based learning and improvement, and Systems-based practice.

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The growth of academic international medicine (AIM) as a distinct field of expertise resulted in increasing participation by individual and institutional actors from both high-income and low-and-middle-income countries. This trend resulted in the gradual evolution of international medical programs (IMPs). With the growing number of students, residents, and educators who gravitate toward nontraditional forms of academic contribution, the need arose for a system of formalized metrics and quantitative assessment of AIM- and IMP-related efforts. Within this emerging paradigm, an institution's “return on investment” from faculty involvement in AIM and participation in IMPs can be measured by establishing equivalency between international work and various established academic activities that lead to greater institutional visibility and reputational impact. The goal of this consensus statement is to provide a basic framework for quantitative assessment and standardized metrics of professional effort attributable to active faculty engagement in AIM and participation in IMPs. Implicit to the current work is the understanding that the proposed system should be flexible and adaptable to the dynamically evolving landscape of AIM – an increasingly important subset of general academic medical activities. The following core competencies are addressed in this article: Patient care, Medical knowledge, Professionalism, Interpersonal and communication skills, Practice-based learning and improvement, and Systems-based practice

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Esophageal rupture is a rupture of the esophageal wall usually brought on by a sudden increase in intraluminal esophageal pressure. This disease is life threatening, and the mortality of patients is time dependent. We describe a case of an elderly woman who presented to the emergency department on 2 consecutive days, the 1^st day with acute lumbar back pain and the 2^nd day critically ill with altered mental status, hypotension, and shortness of breath. The patient was ultimately diagnosed with spontaneous esophageal perforation. The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge, and Patient care.

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Background: Damage control laparotomy with temporary abdominal closure has become routine in trauma surgery. This technique is associated with complications. Increasing prevalence of this procedure leads to concern over abdomens being left open due to decision points other than patient factors, such as routine, time of day, or surgeon fatigue. We hypothesize that time of day contributes to the decision to leave the initial trauma laparotomy open. Materials and Methods: This was a retrospective chart review of 527 patients over 5 years. Patients with emergent damage control laparotomies with fascia not closed were included in the open abdomen group. Those patients who had fascia primarily closed were used as the control group. Patient demographics, injury factors, time of operation, and time to fascial closure were evaluated. Results: Time of day was not predictive of the decision to leave a patient open. In a logistic regression model of these factors, only patient age (P = 0.002), injury severity score (P < 0.0001), and the number of abdominal organs with an injury grade of three or more (P = 0.0014) predicted the abdomen would be left open. Of the patients with initially open abdomen, 101 (72.1%) survived and 77 (76.2%) of those achieved primary fascial closure. Mean time to closure was 3.7 days. Conclusion: The decision to perform damage control surgery and leave an abdomen open appears to be consistent throughout the day and to be dependent on the patient factors. Time of day does not seem to be a contributing factor. Fascial closure, done on average 3.7 days after the initial procedure, does not vary based on the demographic or injury factors. It appears that closure occurs as part of a routine or on convenience. An opportunity may exist to identify a subset of the open abdomen patients that could return to the operating room for earlier definitive closure, thereby lowering the risk of complications. The following core competencies are addressed in this article: Patient care, Practice based learning and improvement, and Systems-based practice.

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Due to the great increase of international travel and emigration, physicians the world over may face serious diagnostic challenges, resulting from the inability to recognize diseases totally alien to their culture, and diseases common to their culture but presenting with previously unseen complications. Over the past 50 years, the frequency of Mycobacterium tuberculosis (MT) infections, arising in the native populations of the United States and other industrialized countries, has been declining. However, the rate of infections in under-developed nations remains at a very high rate. Tuberculosis (TB) can occur in any organ or tissue and can mimic many other diseases. We present the case of a 95-year-old male immigrant from India, with abdominal pain and chronic anemia. Investigation of his abdominal pain revealed a large pancreatic mass with possible hepatic metastases consistent with pancreatic cancer. Fine-needle aspiration biopsy of the mass obtained by endoscopic ultrasound, demonstrated granulomatous inflammation and yielded cultures positive for MT. Antitubercular therapy resulted in progressive resolution of the pancreatic mass and the anemia. The initial clinical impression and radiological findings, in a 95-year-old patient, may well have prompted a harmful decision to opt for comfort care only. This was avoided in our patient by adherence to the strict standard of pursuing a definitive tissue diagnosis for all “masses of unknown origin.” The merits of this case report are in the thorough discussion and illustration of the unusual pathogenesis of TB of the elderly, the imperative of assessing socioeconomic status of patients, and the diagnostic considerations required to evaluate extrapulmonary TB. The following core competencies are addressed in this article: Patient care and Medical knowledge.

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An epidermal cyst is a benign intradermal lesion and may occur anywhere in the body. Carcinoma arising in a preexisting epidermal cyst is uncommon. Cutaneous squamous cell carcinoma is the second most common form of nonmelanoma skin cancer. A 65-year-old male with light skin pigmentation presented with chronic lower back pain secondary to a large “cauliflower-like” mass over his left flank, which started out as a “cheesy tumor” 20 years ago. The patient reported that the mass had recently begun to drain foul-smelling mucous and bloody discharge and was growing in size. This image illustrates the importance of proper comprehensive biannually or annually history and physical examination as screening tools for skin cancer. Primary care physicians are encouraged to educate their patients on the use of sunscreen containing zinc oxide and conducting regular self-examinations. The following core competencies are addressed in this article: Medical knowledge, Patient care.

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Esthesioneuroblastoma was first described by Bergerand Lucin 1924, accounting for 3% of all intranasal tumors. Clinical staging system was proposed by Kadish et al. in 1976 and is used as the prognosis indicator. CT and magnetic resonance imaging are complementary examinations used for the diagnosis, staging and follow-up. The following core competencies are addressed in this article: Medical knowledge, Patient care.

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We report a 67-year-old female with chronic aneurysmal disease of the pancreaticoduodenal arcade due to complete celiac occlusion. The chronic aneurysm had no associated bleeding and was nonemergently embolized. Aneurysms in this location may present acutely with bleeding. A companion case of a 62-year-old male with ruptured aneurysmal disease of the pancreaticoduodenal arcade is also included in this manuscript. The following core competencies are addressed in this article: Medical knowledge, Patient care.

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