Ragheb Assaly

Intravenous lipid emulsion in wide complex arrhythmia with alternating bundle branch block pattern from cocaine overdose.

We describe the management of a young patient who had experienced a cocaine overdose. The patient presented with altered mental status and seizures and subsequently developed a wide complex arrhythmia with a rare alternating bundle branch block pattern. Intravenous lipid emulsion was administered following initial resuscitation and endotracheal intubation, because conservative methods of treating the persistent cardiac arrhythmias failed.

Kaposiform Lymphangiomatosis, a Newly Characterized Vascular Anomaly Presenting with Hemoptysis in an Adult Woman

Disorders of the pulmonary lymphatic system include macro- and microcystic lymphatic malformations, primary or secondary lymphangiectasias, generalized lymphatic anomalies, diffuse pulmonary lymphangiomatosis, and combinations of lymphatic and other tissue anomalies, including lymphangioleiomyomatosis (LAM). We report a case of a patient with a newly defined entity classified as kaposiform lymphangiomatosis (KLA). This 50-year-old nonsmoking Hispanic woman presented with a 20-year history of cough, hemoptysis, chyloptysis, and pleuritic chest pain. Laboratory evaluation demonstrated a low normal platelet count, elevated d-Dimer, low normal fibrinogen, and elevated fibrin split products. Chest computerized tomography imaging showed enlarged hypodense lymph nodes in the mediastinum and hila, and peribronchovascular thickening, without evidence of cystic parenchymal lesions. Magnetic resonance imaging of the chest showed cystic mediastinal lymph nodes with heterogeneously increased T2 and decreased T1 signal intensity. Fiberoptic bronchoscopy revealed hyperemic mucosa with granular appearance suggestive of a submucosal infiltrative process. Pathological specimens revealed dilated, malformed lymphatic channels within the pleura, pulmonary septa, and bronchovascular bundles, and foci of perilymphatic and intralymphatic spindle cells which reacted with the Prospero homeobox protein 1 (PROX-1) immunostain. The morphology and immunohistochemistry results were consistent with a diagnosis of KLA. This newly recognized clinical-pathological entity among intrathoracic lymphatic anomalies is distinguished from generalized lymphatic anomaly and diffuse pulmonary lymphangiomatosis in part by characteristic hematological abnormalities and hemorrhagic complications, including hemoptysis, as experienced by our patient.

Use of multiple fluorophores for evaluating microvascular permeability in control rats and rats with sepsis

Capillary leak accompanying systemic inflammatory response conditions is a significant clinical problem. In the present study, we describe and verify a method for studying capillary leak that is based on the injection of proteins that differ significantly in size and have spectrally distinguishable fluorophores. Control (n=11) and post-CLP (caecal ligation and puncture; n=14) Sprague-Dawley rats were injected with tracer amounts of albumin and PEG-Alb [albumin covalently linked to methoxy-poly(ethylene glycol)] labelled with fluorescein and Texas Red. Blood samples were withdrawn between 5 min and 144 h, and the fluorescence of the labelled proteins was determined. The relative retention of the PEG-Alb and albumin was assessed via measurement of the TER (transcapillary escape rate; in %/h) and the t(50%) estimate, defined as the time when the actual concentration reached 50% of its baseline. The concentration-time trends for both albumin and PEG-Alb tracers exhibited two-compartmental behaviour and were analysed using bi-exponential modelling. Retention times were significantly greater for PEG-Alb in both control and CLP rats. TER(PEG-Alb) was significantly lower than TER(albumin) for both control (8.1+/-5.6 compared with 14.8+/-7.1 %/h respectively; P<0.01) and CLP (14.8+/-6.6 compared with 22.5+/-7.3 %/h respectively; P<0.001) rats. The t(50%[PEG-Alb]) was substantially greater than the corresponding t(50%[albumin]) for both control (29.8+/-9.8 compared with 7.2+/-2.0 h respectively; P<0.001) and CLP (12.9+/-5.6 compared with 5.1+/-1.6 h respectively; P<0.001) rats. The result was similar irrespective of the fluorophore-protein combination, validating the multifluorophore technique. In conclusion, the double-fluorophore approach described in the present study may provide the future basis for a method to quantify capillary leak in disease.

Panel interview for internal medicine residency selection: pros and cons

Selection of residents is an extremely important process for a residency program as it determines the quality of patient care as well as the academic and research progress of the program. Most studies have focused on the relationship between the national board exam scores, such as the United States Medical Licensing Examination (USMLE) and the subsequent clinical performance of the selected residents. However, a low to moderate correlation has been found between board scores and residency performance.1 xa0 n nAdditionally other studies have assessed the residency program directors’ opinions about the relative importance of various selection strategies. They found the top three common selection elements were clerkship grades, reference letters, and the USMLE Step 1 scores.2 n nThere is no consensus as to which selection strategy is the most useful in choosing the candidates. Thus, the existing selection process is not ideal and has many shortcomings. For instance, it may not give an accurate representation of the interviewee as a medical resident.3 Likewise, there may be a major reliance on one parameter, such as the USMLE scores. This may come at the expense of other parameters, such as the candidate’s communication skills, character, and professionalism.4 Also, there is inter- and intra-observer variability in rating the residency candidates. These shortcomings make the selection process subjective and unreliable, which should be avoided when making assessments.5 n nAdopting a new interview style nDuring the 2015-2016 interview season, the University of Toledo Internal Medicine Residency Program introduced a panel-style interview. Previously, the residency program relied on one-on-one interviews with various faculty members to evaluate candidates. Changing the interview style allowed an opportunity for multiple interviewers (the panel) to evaluate a residency candidate. Our panel members consisted of the program director/associate program director, a faculty member, and the chief resident. Also, under the one-on-one interview format, it allowed the interviewer greater access to beforehand knowledge of the candidate, which was changed under the panel interview style. Instead, the interviewers were blinded to the objective criteria, such as USMLE scores. After completion of the interview, the panel members individually scored the residency candidate using various subjective elements, such as communication skills, teaching potential, and professionalism. Subsequently, these scores were used by the residency program to calculate the final rankings of all the candidates during the interview season.

Autopsy learning module: a tool for assessing self-reflection and practice improvement competency

Practice-based learning and improvement is one of the six core competencies listed by the Accreditation Council for Graduate Medical Education (ACGME) for residency programs (post-graduate medical training). ACGME defines practice-based learning and improvement as “an ability to investigate and evaluate the care of patients, appraise and assimilate scientific evidence, and continuously improve patient care based on constant self-evaluation and life-long learning”.1 Assessing resident (also known as housestaff or a house officer) competency in practice-based learning and improvement is the most challenging of the six competencies as there are very few published tools to assess a residents performance in this competency. We aim to develop a standardized resource, which could be utilized by residents for learning and self-reflection, and would also provide evaluators with an objective tool for assessing practice-based learning and improvement competency of residents through an approach known as the “Autopsy Learning Module”. Autopsy has long been recognized as an important tool for learning and quality improvement in clinical practice. Physicians often utilize autopsy findings for evaluating the accuracy of their clinical diagnosis, identifying any unsuspected conditions, and establishing a cause of death. To reiterate the importance of autopsy in medical education, we performed a study through a retrospective chart review of 141 autopsies conducted at our institution between January 2011 and May 2015. We measured the level of agreement between the clinical cause of death established by the treating clinician and the cause of death listed by the pathologist after autopsy using Kappa coefficients. We found there was poor agreement between the clinical and autopsy diagnosis, especially among cases of pulmonary embolism and liver cirrhosis, while there was moderate agreement among cases of myocardial infarction. Our findings were consistent with the available literature.2 The rate of disagreement between the clinical diagnosis and autopsy findings highlights an opportunity to use an autopsy in a meaningful way as both a learning experience and as a tool for self-reflection.

Assessment of ventilator-associated events using the geometric distribution

&NA; Hospital‐acquired rare events, such as nosocomial infections and other low‐occurring incidents, in the clinical environment are difficult to monitor using traditional quality indicators. Using the Centers for Disease Control and Prevention definition of ventilator‐associated events, we demonstrate an alternative method for assessment of rare events.

Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery.

TO THE EDITOR: I read the recent clinical practice guideline on management of venous thromboembolism (1) with great interest; however, I am always suspicious when told that the use of lowmolecular-weight heparin (LMWH) products results in less hemorrhagic complications than does intravenous unfractionated heparin. This is so contrary to my clinical experience. I am also well aware that, as Hippocrates noted, “Experience is delusory.” So my question goes to the original studies analyzed for these guidelines. How many of the underlying studies had no exclusion criteria? In other words, were patients entered into protocols only after screening for chronic kidney disease, age, or other criteria that lead to a greater frequency of hemorrhagic complications? If so, should the guidelines reflect this more explicitly?