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Peer Reviewed

Predictors of an Initial Position in Emergency Medicine

Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 20, Issue 1 (2019)

Introduction: Each year, emergency medicine (EM) residency graduates enter a variety of community and academic positions. For some training programs, the potential for an academic career is a consideration during the interview process; however, no studies have looked at factors that might predict an academic career. Our goal was to identify variables present during the EM application cycle that predict an initial academic position.

Methods: We retrospectively reviewed application materials from 211 EM graduates at Emory University from 2003-2013. We analyzed biographical variables, board scores, personal statements, and both undergraduate and medical school research experience and publications. An academic position was defined as working at a site with residents rotating in the emergency department, full or part-time appointment at a medical school, or a position with research required for promotion. We used a logistic regression model to determine the impact of these predictors on obtaining an initial academic position.

Results: A total of 79 (37%) graduates initially chose an academic job, and 132 (63%) took a community position. We identified the following statistically significant variables: younger age (odds ratio [OR] [0.79], 95% confidence interval [CI] [0.67-0.93], p=0.01); undergraduate publications (OR [1.41], 95% CI [1.08-1.83], p=0.01); and medical school publications (OR [3.39], 95% CI [1.66-6.94], p<0.001). Of note, mention of an academic career in the personal statement showed no statistical correlation (p = 0.41).

Conclusion: Younger age, and undergraduate and medical school publications were the variables most associated with an initial academic position. As this is a single-institution study, more studies are needed to validate these findings.

Cover page: Predictors of an Initial Position in Emergency Medicine

Creative Commons 'BY' version 4.0 license

Article
Peer Reviewed

Hypotension following Patent Ductus Arteriosus Ligation: The Role of Adrenal Hormones

UC San Francisco Previously Published Works (2014)

Objective

To test the hypothesis that an impaired adrenal response to stress might play a role in the hypotension that follows patent ductus arteriosus (PDA) ligation.

Study design

We performed a multicenter study of infants born at <32 weeks' gestation who were about to undergo PDA ligation. Serum adrenal steroids were measured 3 times: before and after a cosyntropin (1.0 μg/kg) stimulation test (performed before the ligation), and at 10-12 hours after the ligation. A standardized approach for diagnosis and treatment of postoperative hypotension was followed at each site. A modified inotrope score (1 × dopamine [μg/kg/min] + 1 × dobutamine) was used to monitor the catecholamine support an infant received. Infants were considered to have catecholamine-resistant hypotension if their greatest inotrope score was >15.

Results

Of 95 infants enrolled, 43 (45%) developed hypotension and 14 (15%) developed catecholamine-resistant hypotension. Low postoperative cortisol levels were not associated with the overall incidence of hypotension after ligation. However, low cortisol levels were associated with the refractoriness of the hypotension to catecholamine treatment. In a multivariate analysis: the OR for developing catecholamine-resistant hypotension was OR 36.6, 95% CI 2.8-476, P = .006. Low cortisol levels (in infants with catecholamine-resistant hypotension) were not attributable to adrenal immaturity or impairment; their cortisol precursor concentrations were either low or unchanged, and their response to cosyntropin was similar to infants without catecholamine-resistant hypotension.

Conclusion

Infants with low cortisol concentrations after PDA ligation are likely to develop postoperative catecholamine-resistant hypotension. We speculate that decreased adrenal stimulation, rather than an impaired adrenal response to stimulation, may account for the decreased production.

Article
Peer Reviewed

Hypotension following Patent Ductus Arteriosus Ligation: The Role of Adrenal Hormones

UCLA Previously Published Works (2014)

Objective

To test the hypothesis that an impaired adrenal response to stress might play a role in the hypotension that follows patent ductus arteriosus (PDA) ligation.

Study design

We performed a multicenter study of infants born at <32 weeks' gestation who were about to undergo PDA ligation. Serum adrenal steroids were measured 3 times: before and after a cosyntropin (1.0 μg/kg) stimulation test (performed before the ligation), and at 10-12 hours after the ligation. A standardized approach for diagnosis and treatment of postoperative hypotension was followed at each site. A modified inotrope score (1 × dopamine [μg/kg/min] + 1 × dobutamine) was used to monitor the catecholamine support an infant received. Infants were considered to have catecholamine-resistant hypotension if their greatest inotrope score was >15.

Results

Of 95 infants enrolled, 43 (45%) developed hypotension and 14 (15%) developed catecholamine-resistant hypotension. Low postoperative cortisol levels were not associated with the overall incidence of hypotension after ligation. However, low cortisol levels were associated with the refractoriness of the hypotension to catecholamine treatment. In a multivariate analysis: the OR for developing catecholamine-resistant hypotension was OR 36.6, 95% CI 2.8-476, P = .006. Low cortisol levels (in infants with catecholamine-resistant hypotension) were not attributable to adrenal immaturity or impairment; their cortisol precursor concentrations were either low or unchanged, and their response to cosyntropin was similar to infants without catecholamine-resistant hypotension.

Conclusion

Infants with low cortisol concentrations after PDA ligation are likely to develop postoperative catecholamine-resistant hypotension. We speculate that decreased adrenal stimulation, rather than an impaired adrenal response to stimulation, may account for the decreased production.

Article
Peer Reviewed

Enteral Feeding during Indomethacin and Ibuprofen Treatment of a Patent Ductus Arteriosus

UC San Francisco Previously Published Works (2013)

Objective

To test the hypothesis that infants who are just being introduced to enteral feedings will advance to full enteral nutrition at a faster rate if they receive "trophic" (15 mL/kg/d) enteral feedings while receiving indomethacin or ibuprofen treatment for patent ductus arteriosus.

Study design

Infants were eligible for the study if they were 23(1/7)-30(6/7) weeks' gestation, weighed 401-1250 g at birth, received maximum enteral volumes ≤60 mL/kg/d, and were about to be treated with indomethacin or ibuprofen. A standardized "feeding advance regimen" and guidelines for managing feeding intolerance were followed at each site (N = 13).

Results

Infants (N = 177, 26.3 ± 1.9 weeks' mean ± SD gestation) were randomized at 6.5 ± 3.9 days to receive "trophic" feeds ("feeding" group, n = 81: indomethacin 80%, ibuprofen 20%) or no feeds ("fasting [nil per os]" group, n = 96: indomethacin 75%, ibuprofen 25%) during the drug administration period. Maximum daily enteral volumes before study entry were 14 ± 15 mL/kg/d. After drug treatment, infants randomized to the "feeding" arm required fewer days to reach the study's feeding volume end point (120 mL/kg/d). Although the enteral feeding end point was reached at an earlier postnatal age, the age at which central venous lines were removed did not differ between the 2 groups. There were no differences between the 2 groups in the incidence of infection, necrotizing enterocolitis, spontaneous intestinal perforation, or other neonatal morbidities.

Conclusion

Infants required less time to reach the feeding volume end point if they were given "trophic" enteral feedings when they received indomethacin or ibuprofen treatments.

Cover page: Enteral Feeding during Indomethacin and Ibuprofen Treatment of a Patent Ductus Arteriosus