Charles W. Hargett

Clinical probability and D-dimer testing: how should we use them in clinical practice?

Venous thromboembolism (VTE) is extraordinarily common and is a major cause of morbidity and mortality. However, accurate and timely diagnosis of VTE is confounded by its kaleidoscopic presentation. Clinical prediction rules (CPRs) and D-dimer testing have both been increasingly employed to clarify the complex decision making required in such cases. Formal clinical pretest probability now serves as the root of algorithms for the diagnosis of DVT and PE. A low pretest probability of VTE plus a negative D dimer can be combined in a bayesian fashion to effectively exclude the diagnosis of VTE. The evidence for this strategy is strongest in younger outpatients with no associated comorbidities, no prior history of VTE, and a short duration of symptoms.

Giant cell interstitial pneumonia associated with nitrofurantoin.

A case of giant cell interstitial pneumonia (GIF) that occurred in association with exposure to nitrofurantoin is presented. While the diagnosis of GIP is confirmed by histopathology, this diagnosis can be supported by the findings of bizarre multinucleated giant cells (MGC), elevated T lymphocytes, and a low T lymphocyte helper/suppressor ratio in the bronchoalveolar lavage fluid (BALF). Recognition of GIP as a rare manifestation of nitrofurantoin toxicity is important because prompt therapy may be associated with a favorable outcome.

What motivates residents to teach? The Attitudes in Clinical Teaching study.

Graduate medical trainees have a critical role in the teaching of other trainees. Improving their teaching requires an understanding of their attitudes towards teaching and their motivation to teach. Both have been incompletely explored in this population. We aimed to better understand graduate medical trainees’ attitudes towards teaching and motivation to teach in the clinical setting in order to inform modifications to resident‐as‐teacher (RAT) programmes and enhance teaching practices.

Thrombolytic therapy for venous thromboembolism: Current clinical practice

BACKGROUND Venous thromboembolism (VTE) is a life-threatening condition for which thrombolytic therapy may be beneficial. The appropriate setting for the use of thrombolytic therapy remains controversial. More than 10 years ago we described the case-based practice patterns for the use of thrombolytics in VTE, and now, in the context of recent studies and guidelines, we sought to reevaluate the use of thrombolytics and to determine whether beliefs have changed. METHODS Active pulmonologists in 11 southeastern states were selected to complete a web-based questionnaire that included background questions and hypothetical case scenarios involving VTE and potential treatment with thrombolytics. RESULTS Eighty-one physicians completed the survey and 84% reported using thrombolytic therapy for VTE within the last 2 years. In the absence of absolute contraindications, 99% of respondents would strongly consider using systemic thrombolytic therapy for massive pulmonary embolism (PE) with hypotension, 83% would strongly consider thrombolysis for a large PE with severe hypoxemia, and 62% would strongly consider thrombolysis for PE with echocardiographic evidence of right ventricular dysfunction. In a patient with massive PE and hypotension with certain contraindications, 91% of respondents would still strongly consider thrombolysis. CONCLUSIONS Most practicing pulmonologists would strongly consider administering thrombolytic therapy for massive PE with hypotension or hypoxemia, and a majority favor thrombolysis for PE in the setting of echocardiographic evidence of right heart dysfunction. Despite the evolving data and guidelines for the management of VTE, our findings are similar to prior survey results, emphasizing the need for further physician education and future randomized trials to clarify the therapy for this potentially deadly condition.

Developing a model for effective leadership in healthcare: a concept mapping approach

Purpose Despite increasing awareness of the importance of leadership in healthcare, our understanding of the competencies of effective leadership remains limited. We used a concept mapping approach (a blend of qualitative and quantitative analysis of group processes to produce a visual composite of the group’s ideas) to identify stakeholders’ mental model of effective healthcare leadership, clarifying the underlying structure and importance of leadership competencies. Methods Literature review, focus groups, and consensus meetings were used to derive a representative set of healthcare leadership competency statements. Study participants subsequently sorted and rank-ordered these statements based on their perceived importance in contributing to effective healthcare leadership in real-world settings. Hierarchical cluster analysis of individual sortings was used to develop a coherent model of effective leadership in healthcare. Results A diverse group of 92 faculty and trainees individually rank-sorted 33 leadership competency statements. The highest rated statements were “Acting with Personal Integrity”, “Communicating Effectively”, “Acting with Professional Ethical Values”, “Pursuing Excellence”, “Building and Maintaining Relationships”, and “Thinking Critically”. Combining the results from hierarchical cluster analysis with our qualitative data led to a healthcare leadership model based on the core principle of Patient Centeredness and the core competencies of Integrity, Teamwork, Critical Thinking, Emotional Intelligence, and Selfless Service. Conclusion Using a mixed qualitative-quantitative approach, we developed a graphical representation of a shared leadership model derived in the healthcare setting. This model may enhance learning, teaching, and patient care in this important area, as well as guide future research.

Sickle cell disease, fat embolism syndrome, and “starfield” pattern on MRI

A 45-year-old man with history of hemoglobin sickle cell disease (SCD) was admitted to the medical intensive care unit from an outside hospital with a several-day history of progressive chest and extremity pain, fever, tachycardia, tachypnea, and hypoxemia, and underwent red cell exchange for acute chest syndrome. He concomitantly developed progressive decline in mental status over several hours. His examination was notable for Glasgow Coma Scale 5 with no motor response to pain, and he was subsequently intubated.