Anjali Bhagra

Fibrin D-Dimer Concentration, Deep Vein Thrombosis Symptom Duration, and Venous Thrombus Volume

Introduction: To determine the relationship between fibrin D-dimer levels, symptom duration, and thrombus volume, consecutive patients with incident deep venous thrombosis (DVT) were evaluated. Methods: In a cross-sectional study design, patient symptom onset was determined by careful patient questioning. Venous thrombosis was confirmed by compression duplex ultrasonography. Thrombus volume was estimated based on patient’s femur length using a forensic anthropology method. Fibrin D-dimer was measured by latex immunoassay. Results: 72 consecutive patients with confirmed leg DVT agreed to participate. The median symptom duration at the time of diagnosis was 10 days. The median D-dimer concentration was 1050 ng/dL. The median thrombus volume was 12.92 cm3. D-Dimer levels correlated with estimated thrombus volume (P < .0006 CI 0.12-0.41; R2 adjusted = .15) but not symptom duration, patient’s age, or gender. Conclusions: Despite varying symptom duration prior to diagnosis, fibrin D-dimer remains a sensitive measure of venous thrombosis and correlates with thrombus volume.

An Assessment of the Incremental Value of the ABCD2 Score in the Emergency Department Evaluation of Transient Ischemic Attack

STUDY OBJECTIVE We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack. METHODS This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days. RESULTS The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days. CONCLUSION The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification.

Point-of-Care Ultrasonography for Primary Care Physicians and General Internists

Point-of-care ultrasonography (POCUS) is a safe and rapidly evolving diagnostic modality that is now utilized by health care professionals from nearly all specialties. Technological advances have improved the portability of equipment, enabling ultrasound imaging to be executed at the bedside and thereby allowing internists to make timely diagnoses and perform ultrasound-guided procedures. We reviewed the literature on the POCUS applications most relevant to the practice of internal medicine. The use of POCUS can immediately narrow differential diagnoses by building on the clinical information revealed by the traditional physical examination and refining clinical decision making for further management. We describe 2 common patient scenarios (heart failure and sepsis) to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure. Using POCUS to guide procedures has been found to reduce procedure-related complications, along with costs and lengths of stay associated with these complications. Despite several undisputed advantages of POCUS, barriers to implementation must be considered. Most importantly, the utility of POCUS depends on the experience and skills of the operator, which are affected by the availability of training and the cost of ultrasound devices. Additional system barriers include availability of templates for documentation, electronic storage for image archiving, and policies and procedures for quality assurance and billing. Integration of POCUS into the practice of internal medicine is an inevitable change that will empower internists to improve the care of their patients at the bedside.

Longitudinal Ultrasound Curriculum Improves Long-Term Retention Among Internal Medicine Residents.

BACKGROUND Point-of-care ultrasound is a rapidly evolving component of internal medicine (IM) residency training. The optimal approach for teaching this skill remains unclear. OBJECTIVE We sought to determine whether the addition of a longitudinal ultrasound curriculum to a stand-alone workshop for ultrasound training improved knowledge retention in IM residents. METHODS We conducted an observational cohort study from July to December 2013. All postgraduate year (PGY)-1 IM residents attended an ultrasound workshop during orientation. Ability to identify static images of ascites, kidney, thyroid, pleural fluid, inferior vena cava, and internal jugular vein was assessed immediately after the workshop. An ultrasound curriculum, including morning report and ultrasound rounds, was initiated during the inpatient medicine rotation. PGY-1 residents were randomly assigned to participate in the longitudinal curriculum. Six months later, we conducted a follow-up survey with all PGY-1 residents. RESULTS Forty-eight PGY-1 residents (67%) completed the postworkshop test and the 6-month follow-up test. Of these, 50% (24 of 48) had participated in the ultrasound curriculum. Residents not exposed to the curriculum showed a decline in the identification of ascites, pleural effusion, and internal jugular vein at 6 months (P < .05), whereas those who participated in the curriculum maintained their performance (P < .05). CONCLUSIONS Six months after exposure to a longitudinal ultrasound curriculum, residents were more likely to correctly identify ultrasound images of ascites, kidney, and pleural effusion. The addition of a longitudinal ultrasound curriculum may result in improved knowledge retention in IM residents.

Ultrasound for Internal Medicine Physicians The Future of the Physical Examination

With the advent of compact ultrasound (US) devices, it is easier for physicians to enhance their physical examinations through the use of US. However, although this new tool is widely available, few internal medicine physicians have US training. This study sought to understand physicians’ baseline knowledge and skill, provide education in US principles, and demonstrate that proper use of compact US devices is a skill that can be quickly learned.

Handheld ultrasound devices and the training conundrum: how to get to "seeing is believing".

Although the ‘‘stethoscope’’ was developed almost 200 years ago by Rene-Theophile-Hyacinthe Laennec and is unquestionably the foundation for classical teaching of the diagnostic physical examination, it is also true that generations of medical students have been exposed to this misnomer. The stethoscope, hung proudly around every medical student’s neck, is indeed a ‘‘stethophone,’’ as it allows listening (steth = chest, phone = sound) to the human body rather than truly seeing (scope = to look in) into it. 1 Recent developments in ultrasound technology have resulted in miniaturization of ultrasound devices, which can be readily carried in a lab coat pocket and used at the bedside to generate high-quality ultrasound images of cardiac structure and function. 2 These devices can provide immediate feedback and extend the information base of the traditionally acquired history and physical examination, contributing to improved cardiac differential diagnosis formulation. 3,4 By visualizing cardiac anatomy and dynamics immediately, using a true stethoscope, the user can refine clinical decision making and optimize the choice of further testing and treatment. 5 Indeed, the use of these devices in routine clinical practice, akin to the manner in which the traditional stethoscope has been used, may potentially enhance, expedite, and improve costefficient care. 6 However, as this technology has only very recently evolved, there is as of yet no standardized approach for teaching the skills necessary to use these devices optimally, nor is there a systematic approach to assessment of the learner’s capabilities and the impact on patient care. Historically, the knowledge base necessary to use the more sophisticated conventional ultrasound scanners has been acquired only at the postgraduate and specialty training levels, at which programmatic instruction and assessments are well established, with numerous accreditation bodies providing benchmarks for expertise and ‘‘quality control.’’ Traditionally, ultrasound assessments have been performed on large scanners located in imaging areas within radiology, cardiology, and obstetrics departments. With the advent of portable scanners in the 1990s, it became possible to scan patients in real time at the ‘‘point of care,’’ and many other specialties such as emergency medicine, surgery, critical care, and others began to embrace ultrasound technology and change their practices. 7 Thus, a technology innovation enabled diverse new groups of users to perform focused ultrasound assessments, which has been further accelerated by the most recent technologic development of ‘‘handheld’’ or ‘‘pocket-sized’’ ultrasound units. Indeed, point-of-care ultrasound can be viewed as a ‘‘disruptive’’ innovation, changing the paradigm of consultative imaging by specialists to one whereby imaging may be performed at the bedside by the clinicians directly responsible for a patient’s care. This activity has the potential advantage not only to enhance the rapidity of imaging access but also to improve the imaging examination through focused acquisition and interpretation guided by the diagnostic context formulated by the consultant directly evaluating the patient. These miniaturized ultrasound devices truly provide widespread opportunity to extend the physical examination of both novice and expert caregivers by seeing directly into the body at the bedside. The equipment is now readily available, at a price point that is not prohibitive to potential mainstream users. The key issue, then, is the development of appropriate training and education of caregivers in their use, so that they will benefit patients, through enhanced cost-effective delivery of care, and not harm them through underdiagnosis or overdiagnosis. Approaches to point-of-care assessments of patients with portable, handheld ultrasound (HHU) units and their integration into both medical teaching and clinical practice are in the ‘‘emergent’’ and ‘‘early adoption’’ stages of new technology. Several medical organizations have recently developed expert consensus and guideline documents aimed at introducing and guiding the use of HHU, particularly as it pertains to cardiac imaging. The American Society of Echocardiography has recognized that these devices are capable of performing focused cardiac ultrasound (FCU) assessments as an adjunct to the physical examination. Whereas HHU describes a portable miniaturized ultrasound device that can be used to examine any organ or system in the body, FCU is specifically defined as a focused examination of the cardiovascular system performed by a physician using ultrasound (at the bedside with an HHU device) as an adjunct to the physical examination to recognize specific ultrasonic signs that represent a

Knowledge of signs, treatment and need for urgent management in patients presenting with an acute ischaemic stroke or transient ischaemic attack: A prospective study

Objective: To assess stroke awareness among patients presenting to the emergency department with an acute ischaemic stroke or transient ischaemic attack (TIA). Methods: A consecutive cohort of patients presenting with a cerebrovascular event was prospectively enrolled over a 15-month period and questionnaires were administered. If the patient was unable to respond to the questions or answer the questionnaire, it was administered to the primary caregiver. Comprehension of having a cerebrovascular event, reason for delay in presentation, mode of arrival and knowledge of treatment modalities were determined. Results: Only 42% of 400 patients thought they were having a stroke or TIA. The median time to presentation was 3.4 h. Delayed presentation was almost equal in men and women. When asked about onset, 19.4% thought that a stroke came on gradually and only 51.9% thought immediate presentation was crucial. 20.8% of patients had heard of thrombolysis. Conclusion: Community knowledge of ischaemic stroke needs to be enhanced so that individuals present earlier, leading to timely management.

Care of the Adult Hodgkin Lymphoma Survivor

Of those individuals diagnosed with Hodgkin lymphoma, 85% will survive and may be affected by residual effects of their cancer and its therapy (chemotherapy, radiation therapy, stem cell transplantation). Hodgkin lymphoma survivors are at risk of developing secondary malignancies, cardiovascular disease, pulmonary disease, thyroid disease, infertility, premature menopause, chronic fatigue, and psychosocial issues. These conditions usually have a long latency and therefore present years or decades after Hodgkin lymphoma treatment, when the patients care is being managed by a primary care provider. This review summarizes these unique potential medical and psychologic sequelae of Hodgkin lymphoma, and provides screening and management recommendations.

Using Standardized Patients to Teach Point-of-Care Ultrasound-Guided Physical Examination Skills to Internal Medicine Residents

BACKGROUND Point-of-care (POC) ultrasound has been shown to improve procedural outcomes and physical examination accuracy in multiple settings. There are limited data regarding the optimal way to train nonradiologists in POC ultrasound. This is a primary barrier to more widespread use of ultrasound in the physical examination. OBJECTIVE We created a workshop to instruct postgraduate year (PGY)-2 and PGY-3 internal medicine residents in POC ultrasound imaging of the abdominal aorta and kidneys. METHODS A half-day simulation center workshop was created to review ultrasound operations and teach residents to independently obtain ultrasound images of the abdominal aorta and kidneys on standardized patients with normal anatomy. The workshop incorporated didactic instruction and hands-on ultrasound practice in small groups. Each residents ability to independently obtain ultrasound images was assessed using a preworkshop and postworkshop skills examination with a standardized patient. Resident knowledge and attitudes toward POC ultrasound were also assessed using a preworkshop and postworkshop test and survey. RESULTS A total of 58 residents completed the workshop, and 84% were able to independently obtain high-quality images of the abdominal aorta and kidney after workshop completion, compared with 16% on the preworkshop test. Residents demonstrated a statistically significant increase in their self-reported confidence with ultrasound operation and image acquisition. CONCLUSIONS Training using standardized patients can prepare residents to independently obtain POC ultrasound images of the aorta and kidneys. Training resulted in increased resident confidence with POC ultrasound and self-reported likelihood of future use.

Efficacy of musculoskeletal injections by primary care providers in the office: a retrospective cohort study

Background Musculoskeletal joint pain of varied etiology can be diagnosed and treated with joint and soft-tissue corticosteroid injections. Purpose The purpose of our study was to compare patients’ bodily pain and quality of life (QOL), in addition to the procedural benefit and patient satisfaction, before and after musculoskeletal injections in the office setting. Patients and methods Patients were eligible for recruitment if they were over age 18 and had an injection for musculoskeletal pain from a primary care provider in an office procedural practice. Included in our analysis were knee joint/bursa, trochanteric bursa, and shoulder joint/bursa injection sites. The variables measured were pain, benefit from the injection, QOL physical and mental components, and patient satisfaction. This was a retrospective cohort study approved by the institutional review board. Results Patients’ pain was assessed by the patients using a six-point Likert scale (none, very mild, mild, moderate, severe, and very severe). We noted that self-perception of pain decreased from 3.10 (± standard deviation at baseline 0.96) before to 2.36 (± standard deviation after the infection 1.21) (P = 0.0001) after the injection. In terms of the impact on QOL, our patients had a pre-injection physical score of 37.25 ± 8.39 and a mental score at 52.81 ± 8.98. After the injections, the physical score improved to 42.35 ± 9.07 (P = 0.0001) and the mental to 53.54 ± 8.20 (P = 0.0001) for the overall group. Ninety-six percent of the patients reported they were satisfied or extremely satisfied in the procedure clinic. Conclusion In this study, we found significant pain relief and improved physical QOL in patients undergoing an injection in the knee joint/bursa, shoulder joint/bursa, or trochanteric bursa by primary care providers in the office setting.