Jason Chertoff

Status of portfolios in undergraduate medical education in the LCME accredited US medical school

Abstract Aim: We sought to investigate the number of US medical schools utilizing portfolios, the format of portfolios, information technology (IT) innovations, purpose of portfolios and their ability to engage faculty and students. Methods: A 21-question survey regarding portfolios was sent to the 141 LCME-accredited, US medical schools. The response rate was 50% (71/141); 47% of respondents (33/71) reported that their medical school used portfolios in some form. Of those, 7% reported the use of paper-based portfolios and 76% use electronic portfolios. Forty-five percent reported portfolio use for formative evaluation only; 48% for both formative and summative evaluation, and 3% for summative evaluation alone. Results: Seventy-two percent developed a longitudinal, competency-based portfolio. The most common feature of portfolios was reflective writing (79%). Seventy-three percent allow access to the portfolio off-campus, 58% allow usage of tablets and mobile devices, and 9% involve social media within the portfolio. Eighty percent and 69% agreed that the portfolio engaged students and faculty, respectively. Ninety-seven percent reported that the portfolios used at their institution have room for improvement. Conclusion: While there is significant variation in the purpose and structure of portfolios in the medical schools surveyed, most schools using portfolios reported a high level of engagement with students and faculty.

Prognostic utility of plasma lactate measured between 24 and 48 h after initiation of early goal-directed therapy in the management of sepsis, severe sepsis, and septic shock

BackgroundBased on the proven efficacy of lactate in predicting mortality and morbidity in sepsis when measured early in the resuscitative protocol, our group hypothesized that this utility extends later in the course of care. This study sought to investigate the prognostic potential of plasma lactate clearance measured 24–48 h after the initiation of treatment for nonsurgical patients with sepsis, severe sepsis, and septic shock.MethodsPlasma lactate values, measured 24–48 h after the initiation of treatment, were collected in nonsurgical septic, severe septic, and septic shock patients. The primary outcome was 30-day mortality, while secondary outcomes included requirements for vasopressors and boluses of intravenous fluids. Analysis of these three outcomes was performed while controlling for clinical severity as measured by Sequential Organ Failure Assessment (SOFA), renal dysfunction, and hepatic dysfunction. Lactate clearance was defined as the percent change in plasma lactate levels measured after 24–48 h of treatment from the plasma lactate level at initial presentation.ResultsTwo hundred twenty-nine nonsurgical patients were divided into two groups, clearers (above median lactate clearance [31.6 %]) and nonclearers (below median lactate clearance [31.6 %]). The adjusted odds ratio of mortality in clearers compared to nonclearers was 0.39 (CI 0.20–0.76) (p = 0.006). For vasopressor requirement, the adjusted odds ratio was 0.41 (CI 0.21–0.79) in clearers compared to nonclearers (p = 0.008). For intravenous fluid bolus requirement, the adjusted odds ratio was 0.81 (CI 0.48–1.39) in clearers compared to nonclearers (p = 0.45).ConclusionsLower plasma lactate clearance 24–48 h after the initiation of treatment is associated with higher 30-day mortality and requirements for vasopressors in nonsurgical septic patients and may be a useful noninvasive measurement for guiding late-sepsis treatment. Further investigation looking at mechanisms and therapeutic targets to improve lactate clearance in late sepsis may improve patient mortality and outcomes.

Transforaminal lumbar interbody fusion rates in patients using a novel titanium implant and demineralized cancellous allograft bone sponge

Background Transforaminal lumbar interbody fusion (TLIF) with grafting and implant options like iliac crest bone graft (ICBG), recombinant bone morphogenetic protein (rhBMP), and polyetheretherketone (PEEK) cages have been reported to achieve extremely high fusion rates. Unfortunately, these options have also been frequently cited in the literature as causing postoperative morbidity and complications at a high cost. Knowing this, we sought to investigate TLIF using an acid-etched, roughened titanium cage that upregulates osteogenesis to see if similar fusion rates to those cited for ICBG, rhBMP, and PEEK cages could be safely achieved with minimal morbidity and complications. Materials and methods A radiographic fusion study of 82 patients who underwent TLIF using an acid-etched, roughened titanium cage with demineralized cancellous bone graft was conducted. Fusion was assessed and graded by an independent radiologist using computed tomography scan with sagittal and coronal reconstructions. Results Fusion rates at 6 months were 41 of 44 (93.2%) and at 12 months were 37 of 38 (97.4%). There were no radiographic device-related complications. Conclusions TLIF with an acid-etched, roughened titanium cage filled with a decalcified bone graft achieved similar fusion rates to historical controls using ICBG, rhBMP, and PEEK.

Azathioprine-induced hepatitis and cholestasis occurring 1 year after treatment

Azathioprine is an immunosuppressive medication used in the management of many autoimmune conditions. Commonly reported adverse effects from azathioprine therapy are nausea and bone marrow suppression, while less common side effects include hepatotoxicity. We present the case of a 47-year-old man with a history of myasthenia gravis on azathioprine for 1 year, who presented to our institution with painless jaundice. On initial laboratory evaluation, the level of aspartate aminotransferase, alanine aminotransferase and total bilirubin were markedly elevated. Owing to the potential diagnosis of acute liver failure secondary to azathioprine toxicity, this medication was discontinued. A liver biopsy demonstrating drug-induced liver injury, along with high serum levels of 6-methylmercaptopurine nucleotide confirmed the diagnosis of azathioprine-induced hepatotoxicity. Upon discontinuation of the medication, the patients transaminases and bilirubin levels improved steadily over the four-day hospital course. This case emphasises azathioprines potential for hepatotoxicity, even 1 year after the initiation of its use.

Pulmonary arterial hypertension and acute respiratory distress syndrome in a patient with adult-onset stills disease:

Adult-onset Still’s disease (AOSD) is an inflammatory disorder characterized by recurrent fevers, arthralgia, leukocytosis, and a salmon-colored rash. Diagnosis is made based on the Yamaguchi criteria. Various cardiac and pulmonary manifestations have been described in association with AOSD, including acute respiratory distress syndrome (ARDS) and pulmonary arterial hypertension (PAH). We describe the first case of both PAH and ARDS in a patient with AOSD who, despite aggressive therapy, declined rapidly and ultimately died. There was concern for pulmonary veno-occlusive disease given the rate of her decompensation, but this was found not to be the case on autopsy. Treatment of AOSD with cardiopulmonary involvement requires rapid identification of AOSD followed by aggressive immunosuppression.

Sepsis outcomes in the correctional system: more potential disparity

1 Wildeman C, Wang EA. Mass incarceration, public health, and widening inequality in the USA. Lancet 2017; 389: 1464–74. 2 Fuller DA, Sinclair E, Geller J, Quanbeck C, Snook J. Going, going, gone: trends and consequences of eliminating state psychiatric beds. June, 2016. Arlington, VA, USA: Treatment Advocacy Center, 2016. http:// www.treatmentadvocacycenter.org/storage/ documents/going-going-gone.pdf (accessed April 16, 2017). 3 Hirschtritt ME, Binder RL. Interrupting the mental illness—incarceration-recidivism cycle. JAMA 2017; 317: 695–96. 4 Fuller, DA, Sinclair, EA, Lamb, HR, Cayce, JD, Snook, J. Emptying the ‘new asylums’: a beds capacity model to reduce mental illness behind bars. January, 2017. Arlington, VA, USA: Treatment Advocacy Center, 2017. http:// www.treatmentadvocacycenter.org/storage/ documents/emptying-new-asylums.pdf (accessed April 16, 2017). 5 Sisti DA, Segal AG, Emanuel EJ. Improving long-term psychiatric care: bring back the asylum. JAMA 2015; 313: 243–44. Mass incarceration and severe mental illness in the USA

Prisoner of My Preconceptions

It was an unusually tranquil day in our medical intensive care unit (MICU). Ventilator alarms were not blaring, intravenous drips were not urgently beeping, and vital sign monitors were not alerting us to any unstable patients. Certainly this calm could not last for long— and it didn’t. I soon overheard our charge nurse mention that a prisoner from a regional correctional facility was in the emergency department (ED) with “really bad sepsis.” “Ugh,” I muttered in quiet annoyance. In my experience, these patients never fared well. Moreover, my cynical side suspected that more wasteful use of limited health care resources was on the horizon. Perhaps I would have felt differently if the patient were not a prisoner; I have no doubt a large part of my reaction was that part of me assumed that anyone who winds up in prison probably is a “bad person.” Four heavy-set grizzly men in tan security guard uniforms accompanied the cachectic prisoner into the MICU. I immediately noticed that he was shackled to the hospital bed by numerous cuffs and full-body restraints, all of which seemed unnecessary since he was heavily sedated, intubated, and mechanically ventilated. It seemed as though the excessive correctional paraphernalia were there simply to indicate the misguided and reckless life choices that he presumably chose. They may as well have written on his forehead, “I am deplorable.” I overheard the signing-off ED nurse say in a monotone voice, “the patient is a 53-year-old male inmate with diffuse large B-cell lymphoma being admitted for presumed septic shock from a necrotic right thigh mass.” “53? He looks more like 83,” I thought in sheer disbelief. I considered what a grueling life this man must have led to look as feeble as he did. Once the transfer was complete and the patient was settled in his room, it was obvious that his sepsis was due to a decaying, malodorous mass protruding from his lower extremity, along with a large left pneumonia and empyema. Standard sepsis bundles and protocols were initiated and the patient continued receiving a broad-spectrum of antibiotics, intravenous fluids, and two vasopressors. For source control, general surgery was consulted for debridement of his grossly infected, necrotic thigh mass, and he would require a chest tube to drain the empyema. I immediately cringed at the assuredly onerous process of obtaining informed consent for the invasive procedures. Consent could not be obtained directly from the patient for obvious reasons, and I was dubious that any family members would be reachable. Even if kin could be reached, I knew of the cumbersome hoops that I would need to surmount to obtain the obligatory consent. I had no time for this right now; the patient was now hemodynamically unstable and his respiratory status was deteriorating. I talked with an intern and asked him to tackle the dreaded consent quandary. Ten minutes later, the intern said to me proudly, “Consents for the procedures are in the chart.” I was flabbergasted and perplexed by the rapidity of the process. Little did I know that the patient was a married man with three children. Also unanticipated was that, despite being incarcerated, the patient was in fairly regular contact with family, which made for an effortless phone conversation between the family and intern, who easily and appropriately obtained consent. As I sterilized and draped the patient in anticipation of his chest tube procedure, I was instantly jolted by compassion as I gazed into his lifeless eyes. I cannot attribute this emotional reaction to any specific event, other than a fortunate revelation. To me, he was suddenly no longer a prisoner; he was a human being who had a wife and children who cared for him. Indeed, he likely made unsound decisions in the past, but right at that moment he did not resemble a convict, but instead a vulnerable person who was gravely ill. It is rare to have such an indelible emotional connection with a complete stranger, especially one whom my past prejudices would have precluded. Like so many prisoners in our MICU, the patient ultimately succumbed to multiorgan failure from sepsis two days later. Although he died, this patient taught me two invaluable lessons that I anticipate will endure throughout my career. First, that my preconceptions of patients based on stereotypes are frequently erroneous. Second, and more importantly, that such stereotypes could stymie optimal patient care and opportunities for personal growth. Indeed, the episode highlighted to me in stark—and disturbing—relief that my passing assumptions about a patient’s personal life and history could affect the effort I invest in cultivating an effective patient-physician relationship. As I considered my experience with the patient, I began to think more broadly about whether prisoners have disparate health care outcomes when compared with the normal civilian population. Not surprisingly, the incarcerated US population presents challenges to the health care system due to a large infectious disease burden, chronic medical conditions, rising costs, and health disparities.1-4 Although prisoners and inmates make up less than 5% of the US population, they bear a disproportionate burden of infectious disease like tuberculosis, HIV/AIDS, hepatitis C, and countless others.3 Moreover, prisoners and inmates are more likely to have chronic noninfectious illnesses like hypertension, asthma, arthritis, cancer, and hepatitis than the general US population.3 The expanding and aging population of the correctional system is certainly driving increasing A PIECE OF MY MIND

Why is prone positioning so unpopular

Recent studies have shown acute respiratory distress syndrome (ARDS) to be underdiagnosed and inadequately treated, as evidenced by underutilization of low-tidal volume ventilation. Despite a proven survival benefit in patients with severe ARDS, studies have also shown underutilization of prone positioning. Many questions persist as to the reasons for prone positioning’s unpopularity. Additional studies are required to uncover the causes of this prone positioning underutilization phenomenon.

You neglected a few

Dear Editor, In their article in the May 2016 issue of Intensive Care Medicine, Dr. Bihari et al. propose ten hypothetical studies that may have the potential to improve management of acute respiratory distress syndrome (ARDS) in the future [1]. Although well articulated and accurately presented, my main contention is that in their ten studies the authors focused on topics that have already been investigated and addressed in prior trials, studies, reviews, and meta-analyses [2, 3]. Instead of fixating on the pathophysiology of ARDS, which so many investigators have already done, I wish that the authors had used their forum to discuss what I believe to be most intriguing about ARDS: the barriers to prone positioning’s widespread adoption in everyday clinical practice. As the authors mention, PROSEVA definitively showed a significant survival benefit from prone positioning in a select subgroup of patients with severe ARDS [4]. In fact, with a 50 % reduction in mortality and a hazard ratio of 0.39, prone positioning for patients with severe ARDS may be more beneficial than any other previously studied intervention for this subgroup of patients [4]. Unfortunately, as seen in the LUNG-SAFE trial, which demonstrated that only 16.4 % of severe ARDS patients are actually proned, prone positioning is presumably vastly underutilized [5]. To my disappointment, instead of addressing this perplexing underutilization phenomenon with potential studies, the authors provided its readers with ten studies that ignore LUNG-SAFE’s disconcerting results [1]. As an exercise to highlight my point, try to imagine the uproar if only 16.4 % of patients with hyperlipidemia refractory to lifestyle changes were prescribed statin therapy, or 16.4 % of patients with diabetes and chronic kidney disease were prescribed angiotensin converting enzyme inhibitors (ACE inhibitors); my guess is that these dismal rates would quickly be addressed. So, some paramount questions continue to remain after reading the authors’ ideas for future ARDS studies and they are: (1) In the appropriate patient, why is prone positioning so underutilized in ARDS management? (2) What studies can we as clinician researchers and educators perform to address this underutilization? (3) What interventions can be performed that address the barriers to widespread adoption and improve the utilization rate of prone positioning? (4) What studies can we perform to test the efficacy of these interventions? Needless to say, there exists an understudied and poorly elucidated discrepancy between prone positioning’s effectiveness and utilization. In addition to the ten studies proposed by Bihari et al., it is also imperative to include researching and addressing the reasons why prone positioning is so unpopular. Perhaps follow-up confirmatory studies to PROSEVA and LUNG-SAFE are required to promote prone positioning’s popularity in severe ARDS management.

A 61-Year-Old Caucasian Woman with Sarcoidosis

Address for Correspondence/Yazışma Adresi: Jason Chertoff E-mail: jason.chertoff@medicine.ufl.edu ©Copyright 2017 by Turkish Anaesthesiology and Intensive Care Society Available online at www.jtaics.org ©Telif Hakkı 2017 Türk Anesteziyoloji ve Reanimasyon Derneği Makale metnine www.jtaics.org web sayfasından ulaşılabilir. Received / Geliş Tarihi : 09.06.2017 Accepted / Kabul Tarihi : 30.08.2017 382 A 61-Year-Old Caucasian Woman with Sarcoidosis Altmış Bir Yaşında Sarkoidozu Olan Beyaz Kadın Hasta