Anthony Donato

Clinical outcomes in patients with isolated subsegmental pulmonary emboli diagnosed by multidetector CT pulmonary angiography.

INTRODUCTION CT Pulmonary Angiography has been shown to be equivalent to Ventilation/ Perfusion scanning in 3-month outcome studies, but it detects more pulmonary emboli. Isolated subsegmental pulmonary emboli are thought to account for some of the increase in diagnosis, but it is not known whether these emboli represent a harbinger for future thromboembolic events. The objective of this study was to determine the 3-month clinical outcomes of a cohort of patients diagnosed with isolated subsegmental pulmonary emboli. MATERIALS AND METHODS Review of 10,453 consecutive CTPA radiology reports over 74-month period since the implementation of Multidetector CT Pulmonary Angiography identified a cohort of 93 patients found to have acute pulmonary embolism isolated to subsegmental pulmonary arteries without other evidence of deep venous thrombosis at one institution. The study measured 3-month clinical outcomes (anticoagulation use, recurrence, death, hemorrhage) determined by review of records and telephone interviews with physicians. RESULTS Seventy-one patients (76%) were treated with anticoagulation and/or IVC filter, while 22 (24%) were observed without therapy. One patient (1/93, 1.05%; 95% CI: 0-6.6%) who was treated with anticoagulants and a vena caval filter had a recurrent subsegmental pulmonary embolus. No patients died of pulmonary embolism. There were 8 hemorrhages, including 5 (5.3%) major hemorrhages without any hemorrhage-related mortality. CONCLUSIONS Patients diagnosed with isolated subsegmental pulmonary emboli have favorable 3-month outcomes. Short-term prognosis for recurrent thromboembolism may be lower than the risk of adverse events with anticoagulation in patients at high risk of hemorrhage.

Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice.

Recent calls for an expanded perspective on medical education and training include focusing on complexities of professional identity formation (PIF). Medical educators are challenged to facilitate the active constructive, integrative developmental process of PIF within standardized and personalized and/or formal and informal curricular approaches. How can we best support the complex iterative PIF process for a humanistic, resilient health care professional? How can we effectively scaffold the necessary critical reflective learning and practice skill set for our learners to support the shaping of a professional identity? The authors present three pedagogic innovations contributing to the PIF process within undergraduate and graduate medical education (GME) at their institutions. These are (1) interactive reflective writing fostering reflective capacity, emotional awareness, and resiliency (as complexities within physician–patient interactions are explored) for personal and professional development; (2) synergistic teaching modules about mindful clinical practice and resilient responses to difficult interactions, to foster clinician resilience and enhanced well-being for effective professional functioning; and (3) strategies for effective use of a professional development e-portfolio and faculty development of reflective coaching skills in GME. These strategies as “bridges from theory to practice” embody and integrate key elements of promoting and enriching PIF, including guided reflection, the significant role of relationships (faculty and peers), mindfulness, adequate feedback, and creating collaborative learning environments. Ideally, such pedagogic innovations can make a significant contribution toward enhancing quality of care and caring with resilience for the being, relating, and doing of a humanistic health care professional.

Evaluation of a novel assessment form for observing medical residents: a randomised, controlled trial

Context  Teaching faculty cannot reliably distinguish between satisfactory and unsatisfactory resident performances and give non‐specific feedback.

A Gut Gone to Pot: A Case of Cannabinoid Hyperemesis Syndrome due to K2, a Synthetic Cannabinoid

Cannabinoid Hyperemesis Syndrome (CHS) was first described in 2004. Due to its novelty, CHS is often unrecognized by clinicians leading to expensive workup of these patients with cyclical symptoms. It may take up to 9 years to diagnose CHS. CHS is characterized by cyclical nausea and vomiting, abdominal pain, and an unusual compulsion to take hot showers in the presence of chronic use of cannabinoids. Cannabicyclohexanol is a synthetic cannabinoid, popularly known as K2 spice. It is a popular marijuana alternative among teenagers and young adults since it is readily available as herbal incense. Unlike marijuana, many users know that K2 is not detected in conventional urine drug screens, allowing those users to conceal their intake from typical detection methods. Serum or urine gas chromatography mass spectrophotometry is diagnostic, though not widely available. Thus, it is imperative for clinicians to recognize CHS, even with negative UDS, to provide cost-effective care. We present a 38-year-old man with a 10-year history of cannabis, and 1-year history of K2 abuse admitted with 1-week history of episodes of nausea, vomiting of clear fluids, and epigastric discomfort. Symptoms are relieved only by hot showers. Extensive laboratory, radiologic, and endoscopic evaluation was unrevealing. CHS was diagnosed, based on proposed criteria by Simonetti et al.

A blueprint for implementation of a structured portfolio in an internal medicine residency.

The Accreditation Council for Graduate Medical Education recommends the structured portfolio as a preferred assessment tool for assessing all six of its core physician competencies. However, compared with other evaluation measures, it may be one of the most resource-intensive for learners and evaluators. Given the time and effort needed to properly develop mentors, train evaluators, and persuade learners, facilitation of the learning environment supporting a portfolio may be the most important variable determining its success or failure. The authors review the components necessary to successfully build and maintain a robust portfolio learning environment in a graduate medical education setting. These include gaining staff acceptance, staging implementation, enhancing learner participation, training mentors, choosing paper versus electronic formats, and selecting assessment methods. Their blueprint for implementing a portfolio is informed by their five-year experience with a portfolio rollout in one internal medicine residency, from 2006 to 2011.

Rituximab-induced serum sickness: A systematic review

OBJECTIVES To report a case of rituximab-induced serum sickness (RISS) and perform a systematic review and characterize RISS in autoimmune diseases and hematological malignancies. METHODS A comprehensive search of MEDLINE, EMBASE, ACR, and EULAR databases was performed for relevant articles of patients with RISS from inception to September 2014. Statistical analysis of demographic and clinical features was performed using Microsoft EXCEL 2007 and SPSS version 20.0. RESULTS In the 33 patients with RISS, the mean age of presentation was 39.1 ± 17.5yr with a female preponderance (n = 23, 76.67%). The majority of cases were associated with an underlying rheumatologic condition (n = 17, 51.5%), most commonly Sjögrens syndrome (n = 8, 44.4%). The classic triad of serum sickness (fever, rash, and arthralgia) was reported in 16 (48.5%) cases. Time from drug exposure to symptom onset was significantly greater with the first doses of rituximab compared to the second dose (mean time 10.00 vs. 4.05d, P = 0.002), and time to resolution was significantly greater for rheumatologic vs. hematological indications (mean time 2.50 vs. 1.00d, P = 0.035). Corticosteroids were the most commonly used treatment (n = 21), with all cases reporting a complete resolution of symptoms in 2.15 ± 1.34d. CONCLUSION It is important to recognize RISS clinically, as it may mimic exacerbation of various rheumatologic conditions. Although RISS is typically self-limited, further infusions of rituximab should be avoided, as it may provoke more severe symptoms.

Predictive accuracy of ST depression during rapid atrial fibrillation on the presence of obstructive coronary artery disease

BACKGROUND Rapid atrial fibrillation (AF) is commonly associated with ST-segment depressions. ST-segment depression during a chest pain episode or exercise stress testing in sinus rhythm is predictive of obstructive coronary artery disease (CAD), but it is unclear if the presence or magnitude of ST-segment depression during rapid AF has similar predictive accuracy. METHODS One hundred twenty-seven patients with rapid AF (heart rate ≥120 beats per minute) who had cardiac catheterization performed during the same hospital admission were retrospectively reviewed. Variables to compute thrombolysis in myocardial infarction (TIMI) risk score, demographic profiles, ST-segment deviation, cardiac catheterization results, and cardiac interventions were collected. RESULTS Thirty-five patients had ST-segment depression of 1 mm or more, and 92 had no or less than 1 mm ST depression. Thirty-one patients were found to have obstructive CAD. In the group with ST-segment depression, 11 (31%) patients had obstructive CAD and 24 (69%) did not. In the group with less than 1 mm ST-segment depression, 20 (22%) had obstructive CAD and 72 (78%) did not (P = .25). Sensitivity, specificity, and positive and negative predictive values for presence of obstructive CAD were 35%, 75%, 31%, and 78%, respectively. The presence of ST-segment depression of 1 mm or more was not associated with presence of obstructive CAD before or after adjustment of TIMI variables. The relationship between increasing grades of ST-segment depression and obstructive CAD showed a trend toward significance (P = .09), which did not persist after adjusting for TIMI risk variables (P = .36). CONCLUSION ST-segment depression during rapid AF is not predictive for the presence of obstructive CAD.

Direct observation of residents: a model for an assessment system.

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

Reliability and acceptability of a five-station multiple mini-interview model for residency program recruitment.

Background Standard interviews are used by most residency programs in the United States for assessment of aptitude of the non-cognitive competencies, but variability of interviewer skill, interviewer bias, interviewer leniency or stringency, and context specificity limit reliability. Aim To investigate reliability and acceptability of five-station multiple mini-interview (MMI) model for resident selection into an internal medicine residency program in the United States. Setting One independent academic medical center. Participants Two hundred and thirty-seven applicants and 17 faculty interviewers. Program description Five, 10-min MMI stations with five different interviewers blinded to the candidates records and one traditional 20-min interview with the program director. Candidates were rated on two items: interpersonal and communication skills, and overall performance. Program evaluation Generalizability data showed that the reliability of our process was high (>0.9). The results of anonymous surveys demonstrated that both applicants and interviewers consider the MMI as a fair and more effective tool to evaluate non-cognitive traits, and prefer the MMI to standard interviews. Discussion The MMI process for residency interviews can generate reliable interview results using only five stations, and it is acceptable and preferred over standard interview modalities by the applicants and faculty members of one US residency program.

Stridor and dysphagia associated with subthalamic nucleus stimulation in Parkinson disease.

Refractory symptoms in Parkinson disease show good response to deep brain stimulation (DBS). This procedure improves United Parkinsons Disease Rating Scale scores and reduces dyskinesias, whereas speech and swallowing dysfunction typically do not improve and may even worsen. Rarely, DBS can cause idiosyncratic dystonias of muscle groups, including those of the neck and throat. The authors describe a patient experiencing stridor and dysphagia with confirmed pulmonary restriction and aspiration following subthalamic nucleus deep brain stimulator adjustment, with a resolution of symptoms and signs when the stimulator was switched off.