Andrew Olson

Physical and Chemical Properties of Bio-Oils From Microwave Pyrolysis of Corn Stover

This study was aimed to understand the physical and chemical properties of pyrolytic bio-oils produced from microwave pyrolysis of corn stover regarding their potential use as gas turbine and home heating fuels. The ash content, solids content, pH, heating value, minerals, elemental ratio, moisture content, and viscosity of the bio-oils were determined. The water content was approx 15.2 wt%, solids content 0.22 wt%, alkali metal content 12 parts per million, dynamic viscosity 185 mPa·s at 40°C, and gross high heating value 17.5 MJ/kg for a typical bio-oil produced. Our aging tests showed that the viscosity and water content increased and phase separation occurred during the storage at different temperatures. Adding methanol and/or ethanol to the bio-oils reduced the viscosity and slowed down the increase in viscosity and water content during the storage. Blending of methanol or ethanol with the bio-oils may be a simple and cost-effective approach to making the pyrolytic bio-oils into a stable gas turbine or home heating fuels.

Antimicrobial stewardship in outpatient settings: a systematic review.

OBJECTIVE Evaluate the effect of outpatient antimicrobial stewardship programs on prescribing, patient, microbial outcomes, and costs. DESIGN Systematic review METHODS Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (eg, infectious conditions, prescription services) evaluating stewardship programs in outpatient settings and reporting outcomes of interest. Data regarding study characteristics and outcomes were extracted and organized by intervention type. RESULTS We identified 50 studies eligible for inclusion, with most (29 of 50; 58%) reporting on respiratory tract infections, followed by multiple/unspecified infections (17 of 50; 34%). We found medium-strength evidence that stewardship programs incorporating communication skills training and laboratory testing are associated with reductions in antimicrobial use, and low-strength evidence that other stewardship interventions are associated with improved prescribing. Patient-centered outcomes, which were infrequently reported, were not adversely affected. Medication costs were generally lower with stewardship interventions, but overall program costs were rarely reported. No studies reported microbial outcomes, and data regarding outpatient settings other than primary care clinics are limited. CONCLUSIONS Low- to moderate-strength evidence suggests that antimicrobial stewardship programs in outpatient settings improve antimicrobial prescribing without adversely effecting patient outcomes. Effectiveness depends on program type. Most studies were not designed to measure patient or resistance outcomes. Data regarding sustainability and scalability of interventions are limited.

Feasibility and acceptability of a structured curriculum in teaching procedural and basic diagnostic ultrasound skills to internal medicine residents.

BACKGROUND Point-of-care ultrasound has emerged as a powerful diagnostic tool and is also being increasingly used by clinicians to guide procedures. Many current and future internists desire training, yet no formal, multiple-application, program-wide teaching interventions have been described. INTERVENTION We describe a structured 30-hour ultrasound training course in diagnostic and procedural ultrasound implemented during intern orientation. Internal medicine interns learned basic ultrasound physics and machine skills; focused cardiac, great vessel, pulmonary, and abdominal ultrasound diagnostic examinations; and procedural applications. RESULTS In postcourse testing, learners demonstrated the ability to acquire images, had significantly increased knowledge scores (P < .001), and demonstrated good performance on practical scenarios designed to test abilities in image acquisition, interpretation, and incorporation into medical decision making. In the postcourse survey, learners strongly agreed (4.6 of 5.0) that ultrasound skills would be valuable during residency and in their careers. CONCLUSIONS A structured ultrasound course can increase knowledge and can result in learners who have skills in image acquisition, interpretation, and integration in management. Future work will focus on refining and improving these skills to allow these learners to be entrusted with the use of ultrasound independently for patient care decisions.

Extreme Hyperferritinemia: Causes and Impact on Diagnostic Reasoning.

OBJECTIVES Hyperferritinemia can be a result of inflammation, infection, chronic iron overload, or other uncommon pathologies including hemophagocytic lymphohistiocytosis (HLH). There is a historical association between extreme hyperferritinemia and HLH, but in reality HLH is associated with a minority of hyperferritinemic states. METHODS We identified conditions most associated with hyperferritinemia by identifying 65,536 serum ferritin levels at the University of Minnesota Hospital over a five-year period, with 86 values higher than 10,000 ng/mL. Pediatric patients comprised 22% of this population, and adults, 78%. RESULTS The majority of cases in both populations with hyperferritinemia were due to chronic transfusion (35%), followed by liver disease (27%), and hematologic malignancy (16%). Solid malignancies, infection, macrophage activation syndrome, and primary and secondary HLH comprised the remaining (22%). CONCLUSIONS Although this supports the relationship between extreme hyperferritinemia and HLH, it maintains that the positive predictive value of hyperferritinemia for HLH is quite low, and one should consider more common explanations before suspecting HLH.

Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events

Diagnostic error is a prevalent, harmful, and costly phenomenon. Multiple national health care and governmental organizations have recently identified the need to improve diagnostic safety as a high priority. A major barrier, however, is the lack of standardized, reliable methods for measuring diagnostic safety. Given the absence of reliable and valid measures for diagnostic errors, we need methods to help establish some type of baseline diagnostic performance across health systems, as well as to enable researchers and health systems to determine the impact of interventions for improving the diagnostic process. Multiple approaches have been suggested but none widely adopted. We propose a new framework for identifying “undesirable diagnostic events” (UDEs) that health systems, professional organizations, and researchers could further define and develop to enable standardized measurement and reporting related to diagnostic safety. We propose an outline for UDEs that identifies both conditions prone to diagnostic error and the contexts of care in which these errors are likely to occur. Refinement and adoption of this framework across health systems can facilitate standardized measurement and reporting of diagnostic safety.

Hypothesis-driven physical examination curriculum

Medical students traditionally learn physical examination skills as a rote list of manoeuvres. Alternatives like hypothesis‐driven physical examination (HDPE) may promote students’ understanding of the contribution of physical examination to diagnostic reasoning. We sought to determine whether first‐year medical students can effectively learn to perform a physical examination using an HDPE approach, and then tailor the examination to specific clinical scenarios.

Running Out of Options: Rhabdomyolysis Associated with Cannabis Hyperemesis Syndrome

Cannabis hyperemesis syndrome (CHS) is a condition in which some patients with long-term, frequent use of cannabis paradoxically develop recurrent episodes of nausea and vomiting. The pathophysiology underlying this condition is poorly understood, as is the explanation for its common association with patients’ discovery that hot-water bathing alleviates symptoms. We describe the case of a 24-year-old male with daily marijuana use and a history of CHS who was found to have rhabdomyolysis induced by a period of 15 h of continuous jogging after he discovered that this activity helped to alleviate his symptoms. To our knowledge, this is the first reported case of exercise-alleviated CHS symptoms, and we propose that this case provides support to the theory of redistribution of enteric blood flow as the mechanism behind the learned hot-water bathing behavior seen so commonly in CHS.

Education for the Next Frontier in Patient Safety: A Longitudinal Resident Curriculum on Diagnostic Error

Diagnostic error is a common, serious problem that has received increased attention recently for its impact on both patients and providers. Presently, most graduate medical education programs do not formally address this topic. The authors developed and evaluated a longitudinal, multimodule resident curriculum about diagnostic error and medical decision making. Key components of the curriculum include demystifying the medical decision-making process, building skills in critical thinking, and providing strategies for diagnostic error mitigation. Special attention was paid to avoiding the second victim effect and to fostering a culture that supports constructive, productive feedback when an error does occur. The curriculum was rated by residents as helpful (96%), and residents were more likely to be aware of strategies to reduce cognitive error (27% pre vs 75% post, P < .0001) following its implementation. This article describes the development, implementation, and effectiveness of this curriculum and explores generalizability of the curriculum to other programs.

Not a textbook case

Andrew P. J. Olson, MD*, Nishant Sahni, MD, MS, Benjamin Kim, MD, MPhil, Gurpreet Dhaliwal, MD Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota; Division of Hematology/Oncology; Department of Medicine, University of California San Francisco, San Francisco, California; Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, California.

The Hypothesis-Driven Physical Examination

The physical examination remains a vital part of the clinical encounter. However, physical examination skills have declined in recent years, in part because of decreased time at the bedside. Many clinicians question the relevance of physical examinations in the age of technology. A hypothesis-driven approach to teaching and practicing the physical examination emphasizes the performance of maneuvers that can alter the likelihood of disease. Likelihood ratios are diagnostic weights that allow clinicians to estimate the post-probability of disease. This hypothesis-driven approach to the physical examination increases its value and efficiency, while preserving its cultural role in the patient-physician relationship.