Early detection of diseases such as COVID-19 could be a critical tool in reducing disease transmission by helping individuals recognize when they should self-isolate, seek testing, and obtain early medical intervention. Consumer wearable devices that continuously measure physiological metrics hold promise as tools for early illness detection. We gathered daily questionnaire data and physiological data using a consumer wearable (Oura Ring) from 63,153 participants, of whom 704 self-reported possible COVID-19 disease. We selected 73 of these 704 participants with reliable confirmation of COVID-19 by PCR testing and high-quality physiological data for algorithm training to identify onset of COVID-19 using machine learning classification. The algorithm identified COVID-19 an average of 2.75 days before participants sought diagnostic testing with a sensitivity of 82% and specificity of 63%. The receiving operating characteristic (ROC) area under the curve (AUC) was 0.819 (95% CI [0.809, 0.830]). Including continuous temperature yielded an AUC 4.9% higher than without this feature. For further validation, we obtained SARS CoV-2 antibody in a subset of participants and identified 10 additional participants who self-reported COVID-19 disease with antibody confirmation. The algorithm had an overall ROC AUC of 0.819 (95% CI [0.809, 0.830]), with a sensitivity of 90% and specificity of 80% in these additional participants. Finally, we observed substantial variation in accuracy based on age and biological sex. Findings highlight the importance of including temperature assessment, using continuous physiological features for alignment, and including diverse populations in algorithm development to optimize accuracy in COVID-19 detection from wearables.

OBJECTIVES:Implicit bias contributes to both health care disparities and professional limitations, and it exists among physicians. Prior literature has described physician weight bias (WB) toward patients, but little research has investigated interphysician WB. This study describes the prevalence of interphysician implicit WB and investigates the relationships between implicit, explicit, and professional biases. The authors hypothesized that the majority of physicians possess interphysician implicit WB and that the degree of implicit bias has a direct relationship with explicit and professional WB.METHODS:In this cross-sectional study, a survey was used to measure interphysician implicit, explicit, and professional WB. It included adaptations of two previously validated measures (the Implicit Association Test and the Crandall Anti-fat Attitudes Questionnaire) and an investigator developed and tested Professional Weight Bias Scale. The survey was distributed electronically via medical society message boards, email lists, and social media groups.RESULTS:A total of 620 physicians and medical students participated. Fifty-eight percent were female, ages ranged from 22 to 83 years (mean = 44 years), and body mass index (BMI) ranged from 16 to 59 (mean = 26). Descriptive analyses revealed that 87% had some degree of implicit interphysician antifat bias, with 31% and 34% categorized as moderate and severe, respectively. Correlation and multiple regression analyses revealed that male sex, increased age, and decreased BMI were related to increased implicit bias, controlling for all other factors. Furthermore, implicit, explicit, and professional bias all had significant, direct relationships with each other.CONCLUSIONS:Our findings highlight the prevalence of interphysician implicit WB; the strong correlations between implicit, explicit, and professional WB; and the potential disparities faced by physicians with obesity. These results may be used to guide implicit bias training for a more inclusive medical workplace.

Take-Home MessageOverall, first-attempt intubation success rates are similar between bougie and stylet.MethodsData SourcesPubMed, EMBASE, and Cochrane Library databases were searched for studies published before November 2018. No language restrictions were applied.Study SelectionOnly randomized controlled trials comparing intubation with either bougie or stylet were included. Studies were required to report clear inclusion and exclusion criteria, intubation technique, first-attempt intubation success rate, and intubation duration to be included in the systematic review and meta-analysis. Manikin, simulation, and cadaver studies were excluded.Data Extraction and SynthesisData of interest were independently extracted by 2 of the authors, and the senior author resolved any disagreements. The methodological quality of each study was assessed by 2 authors using the Cochrane Risk of Bias Tool. Meta-analysis was conducted with a random-effects model. The primary outcome of interest was the first-attempt success rate and secondary outcomes were intubation duration and esophageal intubation rate. Risk ratios (RR) were used for dichotomous outcomes and weighted mean differences for continuous outcomes. Overall, first-attempt intubation success rates are similar between bougie and stylet. PubMed, EMBASE, and Cochrane Library databases were searched for studies published before November 2018. No language restrictions were applied. Only randomized controlled trials comparing intubation with either bougie or stylet were included. Studies were required to report clear inclusion and exclusion criteria, intubation technique, first-attempt intubation success rate, and intubation duration to be included in the systematic review and meta-analysis. Manikin, simulation, and cadaver studies were excluded. Data of interest were independently extracted by 2 of the authors, and the senior author resolved any disagreements. The methodological quality of each study was assessed by 2 authors using the Cochrane Risk of Bias Tool. Meta-analysis was conducted with a random-effects model. The primary outcome of interest was the first-attempt success rate and secondary outcomes were intubation duration and esophageal intubation rate. Risk ratios (RR) were used for dichotomous outcomes and weighted mean differences for continuous outcomes. Tabled 1Pooled outcomes for first-pass success, intubation duration, and esophageal intubation.Outcome MeasuredNo. of Studies (No. of Patients)No. of Events (Total Patients), Bougie vs StyletMeta-analysis Summative Data (95% CI)I2, %First-pass success, bougie vs stylet5 (1,038)472 (516) vs 434 (522)RR1.03 (0.85 to 1.24)87Intubation duration, bougie vs stylet, s5 (1,038)476 (516) vs 473 (522)MD6.01 (–0.07 to 12.09)92Esophageal intubation, bougie vs stylet4 (978)3 (486) vs 7 (492)RR0.059 (0.013 to 2.59)11MD, Mean difference in seconds. Open table in a new tab MD, Mean difference in seconds. The initial literature search yielded 370 studies. After screening of title and abstracts, 43 full texts required review, with 5 studies included for meta-analysis. There were a total of 1,038 patients; the majority of subjects were from one large emergency department (ED) study (N=757) by Driver et al1Driver B.E. Prekker M.E. Klein L.R. et al.Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial.JAMA. 2018; 319: 2179-2189Crossref PubMed Scopus (133) Google Scholar and an out-of-hospital–based study by Heegaard et al2Heegaard W.G. Black C. Pasquerella C. et al.Use of the endotracheal tube introducer as an adjunct for oral tracheal intubation in the prehospital setting.Air Med J. 2003; 22: 28-31Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar (N=51). The remainder of subjects were from 3 preoperative studies (total N=230).3Gataure P.S. Vaughan R.S. Latto I.P. Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet.Anaesthesia. 1996; 51: 935-938Crossref PubMed Scopus (114) Google Scholar, 4Noguchi T. Koga K. Shiga Y. et al.The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet.Can J Anaesth. 2003; 50: 712-717Crossref PubMed Scopus (58) Google Scholar, 5Tosh P. Rajan S. Kumar L. Ease of intubation with C-MAC videolaryngoscope: use of 60° angled styletted endotracheal tube versus intubation over bougie.Anesth Essays Res. 2018; 12: 194-198Crossref Google Scholar Risk of bias was considered high only in the out-of-hospital study. Overall, first-attempt intubation success, intubation duration, and the esophageal intubation rates were similar between bougie and stylet groups, with RR 1.03 (95% confidence interval [CI] 0.85 to 1.24), mean difference 6.01 (95% CI –0.07 to 12.09), and RR 0.59 (95% CI 0.13 to 2.59), respectively (Table). Successful intubation on the first attempt is critical to minimize peri-intubation adverse events because the risk of adverse events increases with the number of intubation attempts.6Brown III, C.A. Bair A.E. Pallin D.J. et al.NEAR III InvestigatorsTechniques, success, and adverse events of emergency department adult intubations.Ann Emerg Med. 2015; 65: 363-370Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar,7Sakles J.C. Chiu S. Mosier J. et al.The importance of first pass success when performing orotracheal intubation in the emergency department.Acad Emerg Med. 2013; 20: 71-78Crossref PubMed Scopus (313) Google Scholar Tools such as the gum elastic bougie are being used to maximize the chances of first-pass success in EDs, mostly for suspected difficult intubations. This meta-analysis found no difference in intubation outcomes between bougie and stylet in a variety of intubators. This meta-analysis has several limitations. The studies were heterogeneous with respect to type of intubator and location of procedure. In the out-of-hospital study, paramedics likely had less experience with the bougie compared with the emergency physicians in the ED study.1Driver B.E. Prekker M.E. Klein L.R. et al.Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial.JAMA. 2018; 319: 2179-2189Crossref PubMed Scopus (133) Google Scholar,2Heegaard W.G. Black C. Pasquerella C. et al.Use of the endotracheal tube introducer as an adjunct for oral tracheal intubation in the prehospital setting.Air Med J. 2003; 22: 28-31Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar In the ED-based study, 80% of intubations were performed with a bougie before the start of the trial.1Driver B.E. Prekker M.E. Klein L.R. et al.Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial.JAMA. 2018; 319: 2179-2189Crossref PubMed Scopus (133) Google Scholar In one of the preoperative studies, the anesthesiologist created a “simulated difficult intubation,” limiting generalizability.3Gataure P.S. Vaughan R.S. Latto I.P. Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet.Anaesthesia. 1996; 51: 935-938Crossref PubMed Scopus (114) Google Scholar The trials were not blinded; the clinicians performing the procedure were aware of the allocation group, as were the outcome assessors. Overall first-pass successful intubation rates are greater than 85% in many EDs, and as a result, identifying techniques that improve on this rate may be challenging. The bougie was designed as a rescue device for difficult intubations, and therefore it is likely harder to demonstrate improvement in metrics for routine intubations in which success is expected regardless of the operator and regardless of the adjunct tool used. Although the meta-analysis did not demonstrate a difference between bougie and stylet use, the results from the 2 randomized trials most relevant to emergency physicians (ED-based study and the out-of-hospital study) demonstrate a correlation with increased first-pass success with the use of a bougie.1Driver B.E. Prekker M.E. Klein L.R. et al.Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial.JAMA. 2018; 319: 2179-2189Crossref PubMed Scopus (133) Google Scholar,2Heegaard W.G. Black C. Pasquerella C. et al.Use of the endotracheal tube introducer as an adjunct for oral tracheal intubation in the prehospital setting.Air Med J. 2003; 22: 28-31Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Because the providers in the ED-based study had significant experience with the bougie before the start of the trial, how the bougie performs when used by other ED providers is unknown. Although the bougie may be a valuable adjunct, providers may need sufficient training and skill to benefit from its use. Finally, all usage of the bougie in these studies entailed “railroading” it, as opposed to preloading the endotracheal tube onto the bougie. Future research is needed to evaluate the use of the bougie with other ED providers and in different modalities.

Emergency medicine (EM) remains a competitive specialty, and the residency application process is arduous. Medical students are applying to and interviewing at a record number of programs, and an additional stressor has been added with the introduction of the standardized video interview. Students have, for years, perceived the residency match process as opaque and high-stakes, and the competitiveness of our specialty in tandem with the novel facets of the process may be increasing that stress. The informal sharing of rotation and interview experiences and unpublished program information has always been a source of comfort and clarity to the applicant during this challenging time. The current generation of students is unique relative to their predecessors in that they expect program information to be transparent, detailed, and easily available. Indeed, a gap may exist between what is expected by these applicants and what is provided by the AAMC, medical schools, hospitals, and residency programs. We suspect that such a disconnect between expectations and reality in the midst of a stress-laden process has resulted in unprofessional coping mechanisms by some students, and these have been immortalized in online digital media. In recent years, as digital media have permeated many segments of our daily lives, students have turned to online forums such as Student Doctor Network (SDN) and Reddit to seek crowdsourced data and a supportive community. During the 2018 to 2019 application season, a shared open-access and freely editable online spreadsheet was utilized by medical students applying for postgraduate training in the United States. The document contained candid reflections on rotations, interviews, rank lists, and anecdotal data from presumed applicants. There are several examples in which students’ opinions, frustrations, and dissatisfaction are expressed with sexually explicit, hateful, misogynistic, violent, homophobic, racist, crude, and threatening language. In addition, there is language that is less vulgar yet still overtly unprofessional and disparaging to schools, residency programs, named individuals, and anonymous coposters. While a majority of these comments were made with “throwaway” accounts, the context in which they appear makes clear

Children commonly present to emergency departments with foreign bodies in the ear. In addition, physicians place wicks in the ear canal as part of the treatment of otitis externa. Usually, these foreign bodies are easily removed, but occasionally, removal must be deferred or is delayed by parents. Therefore, the dangers of retained foreign bodies are important for the emergency physician to be aware of. We report the highly unusual case of a 12-year-old girl who presented with ear pain for 3 weeks. She was found to have an ear wick in place as part of the treatment of otalgia. She was subsequently diagnosed with mastoiditis and meningitis. This is first time mastoiditis and meningitis has been reported as a complication of ear wick placement, although not the only case of an intracranial complication of an aural foreign body.

We describe the case of a 44-year-old man who presented to the Emergency Department (ED) complaining of pain and swelling over the left elbow of 1-week duration. After olecranon bursal aspiration, synovial fluid analysis yielded an increased white blood cell count (3040 cells/mm(3)) and the presence of bacteria. Culture of the fluid later grew Staphylococcus aureus. The patient was initially treated with oral antibiotics for septic bursitis and returned to the orthopedics clinic for follow-up 2 days later with interval worsening of symptoms. He was subsequently admitted for parenteral antibiotics and surgical wash-out of the affected bursa. This report briefly discusses the clinical history and appropriate diagnostic evaluation for septic olecranon bursitis, as well as the shortcomings of existing treatment guidelines.