Scott A. Dulchavsky

A pilot study of comprehensive ultrasound education at the Wayne State University School of Medicine: A pioneer year review

Objective. Ultrasound is a versatile diagnostic modality used in a variety of medical fields. Wayne State University School of Medicine (WSUSOM) is one of the first medical schools in the United States to integrate an ultrasound curriculum through both basic science courses and clinical clerkships. Methods. In 2006, 25 portable ultrasound units were donated to WSUSOM. First‐year medical students were provided an ultrasound curriculum consisting of 6 organ‐system sessions that addressed the basics of ultrasound techniques, anatomy, and procedural skills. After the last session, students were administered 2 anonymous and voluntary evaluations. The first assessed their overall experience with the ultrasound curriculum, and the second assessed their technical skills in applying ultrasound techniques. Results. Eighty‐three percent of students agreed or strongly agreed that their experience with ultrasound education was positive. On the summative evaluation, nearly 91% of students agreed or strongly agreed that they would benefit from continued ultrasound education throughout their 4 years of medical school. Student performance on the technical assessment was also very positive, with mean class performance of 87%. Conclusions. As residency programs adopt ultrasound training, medical school faculty should consider incorporating ultrasound education into their curriculum. Portable ultrasound has the potential to be used in many different settings, including rural practice sites and sporting events. The WSUSOM committees pilot ultrasound curriculum will continue to use student feedback to enhance the ultrasound experience, helping students prepare for challenges that they will face in the future.

The hand-held FAST: experience with hand-held trauma sonography in a level-I urban trauma center.

AIMS To describe the effectiveness of a portable hand-held ultrasound machine when used by clinicians in the early evaluation and resuscitation of trauma victims. METHODS The study was a prospective evaluation in a level-I urban trauma center. The focussed assessment with sonography for trauma is a specifically defined examination for free fluid known as the focused assessment with sonography for trauma (FAST) exam. Seventy-one patients had a hand-held FAST (HHFAST) examination performed with a Sonosite 180, 2.4 kg ultrasound machine. Sixty-seven examinations were immediately repeated with a Toshiba SSH 140A portable floor-based machine. This repeat scan (formal FAST or FFAST) was used as a comparison standard between the devices for study purposes. Four patients had a HHFAST only, all with positive result, two being taken for immediate laparotomy, and two having a follow-up computed tomographic (CT) scan. Patient follow-up from other imaging studies, operative intervention, and clinical outcomes were also compared to the performance of each device. RESULTS There were 58 victims of blunt, and 13 of penetrating abdominal trauma. One examination was indeterminate using both machines. The apparent HHFAST performance yielded; sensitivity, specificity, positive predictive value, negative predictable value, and accuracy (S, S, PPV, NPV, A) of 83, 100, 100, 98, 98%. Upon review, a CT scan finding and benign clinical course found the HHFAST diagnosis to be correct rather than the FFAST in one case. Considering the ultimate clinical course of the patients, yielded a (S, S, PPV, NPV, A) of 78, 100, 100, 97, and 97% for the HHFAST and 75, 98, 86, 97, and 96% for the FFAST. Statistically, there was no significant difference in the actual performance of the HHFAST compared to the FFAST in this clinical setting. DISCUSSION Hand-held portable sonography can simplify early and accurate performance of FAST exams in victims of abdominal trauma.

Gallbladder and biliary tract candidiasis

BACKGROUND The clinical significance of Candida spp isolated from the gallbladder on the biliary tract is relatively unknown. METHODS To provide this information, patients with Candida spp isolated from gallbladder and other biliary tract sources during a 10-year period were identified through the records of our clinical microbiology laboratory. Medical records were analyzed for biliary disease causes, culture data, treatment, and outcome. RESULTS Twenty-seven patients were identified. Five of seven patients with cholecystitis were critically ill intensive care unit (ICU) patients in whom the mortality rate was 100%. Gallstone pancreatitis was found in four patients and was fatal in one patient with a pancreatic abscess and ongoing retroperitoneal sepsis. An external biliary shunt/endoprosthesis was placed in 16 patients to relieve biliary obstruction. Cholangitis was present in 14 patients, and most bile cultures contained Candida as part of a mixed flora. Only 3 of 27 patients had candidemia, and 22 of 27 patients were colonized with Candida at other sites. CONCLUSIONS (1) The ICU patient with Candida cholecystitis has a grave prognosis. (2) Patients with Candida isolated from biliary stents placed for obstruction and cholangitis should be treated with both antifungal and broad spectrum antimicrobial agents. (3) Candidemia is not frequently seen in this setting.

Focused assessment with sonography for trauma in weightlessness: a feasibility study

BACKGROUND The Focused Assessment with Sonography for Trauma (FAST) examines for fluid in gravitationally dependent regions. There is no prior experience with this technique in weightlessness, such as on the International Space Station, where sonography is currently the only diagnostic imaging tool. STUDY DESIGN A ground-based (1 g) porcine model for sonography was developed. We examined both the feasibility and the comparative performance of the FAST examination in parabolic flight. Sonographic detection and fluid behavior were evaluated in four animals during alternating weightlessness (0 g) and hypergravity (1.8 g) periods. During flight, boluses of fluid were incrementally introduced into the peritoneal cavity. Standardized sonographic windows were recorded. Postflight, the video recordings were divided into 169 20-second segments for subsequent interpretation by 12 blinded ultrasonography experts. Reviewers first decided whether a video segment was of sufficient diagnostic quality to analyze (determinate). Determinate segments were then analyzed as containing or not containing fluid. A probit regression model compared the probability of a positive fluid diagnosis to actual fluid levels (0 to 500 mL) under both 0-g and 1.8-g conditions. RESULTS The in-flight sonographers found real-time scanning and interpretation technically similar to that of terrestrial conditions, as long as restraint was maintained. On blinded review, 80% of the recorded ultrasound segments were considered determinate. The best sensitivity for diagnosis in 0 g was found to be from the subhepatic space, with probability of a positive fluid diagnosis ranging from 9% (no fluid) to 51% (500 mL fluid). CONCLUSIONS The FAST examination is technically feasible in weightlessness, and merits operational consideration for clinical contingencies in space.

T3 preserves respiratory function in sepsis.

Sepsis produces profound hypothyroidism. This hypothyroid state is associated with altered lung metabolism and structural integrity. We studied the respiratory function of rats during sepsis-induced hypothyroidism with or without T3 treatment. Forty-four male Holtzman rats underwent cecal ligation and puncture (CLP). Treatment was administered at six hours after surgery consisting of intraperitoneal injection of T3 (15 micrograms/kg, n = 19) or saline (n = 25). At 20 hours (Group A) or 30 hours (Group B) following CLP, respiratory drive was assessed by serial occlusion pressure technique (P0.1). The rats were killed and static elastance determined by serial air inflation to 10 cc. The lungs were excised for weight determination. The P0.1 values were significantly greater in T3-treated animals over controls in Group A (9.3 +/- 0.7 vs. 6.6 +/- 2.2, p less than 0.05 by t test); elastance was significantly improved by T3 treatment in Group B (p less than 0.05 by two-way ANOVA). Lung weight, pH, pO2, pCO2, respiratory rate (RR), and mortality were not significantly different between groups. Control animals were hypothyroid by 20 hours after CLP (T3 less than 12.5 ng/dL) whereas T3-treated animals were euthyroid (T3 = 145 +/- 43 ng/dL). Pulmonary dysfunction frequently accompanies sepsis; the euthyroid state appears protective. We found a significantly improved respiratory drive in septic animals with T3 treatment. Lung elastance was similarly improved in late sepsis with T3 treatment. The data suggest that T3 treatment preserves respiratory function in septic rats as evidenced by respiratory drive and compliance.

Enterocyte apoptosis and barrier function are modulated by SIgA after exposure to bacteria and hypoxia/reoxygenation

BACKGROUND Secretory immunoglobulin A (SIgA) is the principal immune defense against luminal pathogens at gut mucosal surfaces. It also has anti-inflammatory activities that may be important for the maintenance of mucosal surface integrity. Enterocyte apoptosis (Apo) is increased after challenge with invasive bacteria and ischemia-reperfusion insults. Increased Apo also has been associated with impaired intestinal barrier function. However, the impact of SIgA on enterocyte apoptosis and mucosal barrier integrity after challenge with commensal bacteria and ischemia-reperfusion is unknown. METHODS Caco2 intestinal epithelial cell monolayers were subjected to 21% O(2) (control) or 95% N(2)/15% CO(2) (hypoxic) conditions for 90 minutes, followed by 21% O(2). Escherichia coli and SIgA were added in subsets. Caco2 cell Apo was identified by flow cytometry and barrier function indexed by permeability to dextran-fluorescein isothiocyanate. RESULTS There were no differences in the percentage of Apo Caco2 cells after exposure to either bacteria or hypoxic-reoxygenation versus control. There was a significant increase in Apo after the combined bacteria/hypoxia-reoxygenation challenge. SIgA abrogated the Apo response and preserved barrier function after this combined challenge. CONCLUSION Modulation of enterocyte Apo by SIgA may serve to maintain intestinal barrier function and thereby decrease the systemic inflammatory response after clinical conditions associated with gut ischemia-reperfusion insults.

Effect of Maharishi AK-4 on H2O2-induced oxidative stress in isolated rat hearts

Oxidative damage to crucial biomolecules due to excess generation of reactive oxygen species has been implicated as a major cause of organ damage and hence compounds capable of negating such damage have potential benefits. Using hydrogen peroxide (H2O2) as a model pro-oxidant to induce oxidative stress, we have examined the ability of natural food supplement Maharishi Amrit Kalash (MAK-4) to decrease oxidative damage in potassium-arrested isolated rat hearts. The protocol was that hearts isolated from male Sprague-Dawley rats were retrograde-perfused with Krebs-Henseleit (K-H) solution for 30 min for equilibration. After this period, the hearts were subjected to cardioplegia with high potassium (26-30 mM), followed by reperfusion with K-H solution in the presence or absence of 200 microM H2O2. As expected, H2O2 treatment following cardioplegia induced a high degree of oxidative stress as assessed by release of lactate dehydrogenase (LDH, a marker of plasma membrane damage) and total glutathione (GSH + GSSG). H2O2 also impaired the ability of heart to regain developed tension during the testing period. However, addition of MAK-4 in the perfusate containing H2O2 decreased oxidative stress in terms of release of LDH and glutathione. In parallel with these biochemical studies, in a few experiments the cardiac function was assessed by measuring developed contractile tension. These preliminary studies also showed that in the presence of MAK-4 the H2O2-treated hearts were able to regain better developed tension. Further in vitro studies to examine the possible mechanisms of MAK-4 action reveal that this formulation contains H2O2 binding activity which resulted in the decreased availability of H2O2 itself. Our studies hence reveal that the ayurvedic food supplement MAK-4 may have potential benefits in reducing oxidative stress.

Effects of Triiodothyronine (T3) Supplementation Upon Ozone-Induced Lung Injury

Ozone exposure results in an acute decrease in the serum levels of thyroid hormones; the physiologic sequelae of this are unclear. Whereas thyroid hormone supplementation appears to benefit pulmonary function in septic, oxyradical models of injury, thyroid hormone increases ozone toxicity. We demonstrated an increase in metabolic rate and pulmonary injury in lungs from ozone exposed, T3 treated animals. This was evidenced by an increase in pulmonary weight gain, vascular perfusion pressure, and decrease in compliance in the supplemented animals. However, an increase in alkane generation, as an index of lipid peroxidation, was not seen in the ozone exposed, hormonally treated animals. This suggests that although thyroid hormone supplementation increases metabolic rate and ozone toxicity, an increased rate of lipid peroxidation plays a minimal role.

Synergies between Space Research and Space Operations— Examples from the International Space Station

Primary objectives for the International Space Station (ISS) in support of the Vision for Space Exploration include conducting research to counteract the harmful effects of space on human health, test new space technologies, and learn to operate long-duration space missions. In pursuit of these objectives, NASA is interested in closer cooperation between the ISS operational community, scientists, and engineers. To develop the exploration vehicles for missions to the moon and Mars, NASA must test materials, foods, and medicines to ensure their performance in the space environment. These results will enable important decisions on the materials to be used for future space vehicles. Another critical factor for the success on future missions beyond Earth orbit is the capability for repairs of equipment. On the ISS, the practice of crewmembers performing repairs in microgravity will increase our understanding of the repair processes in space; when these capabilities are needed during future space exploration missions, we will have the knowledge and experience to perform them. The ISS is a unique and irreplaceable training ground for building the operational knowledge required to safely conduct future exploration missions, and the growing links within the science, engineering and operations communities are reinforcing the value of that training. Current interactions between the communities that support the ISS have already produced many synergies that are significantly accelerating NASAs advancement towards future exploration missions in support of the Vision.

Commentary on: Racial disparity in New Orleans: A faith-based approach to an age-old problem

PROVIDING ACCESS AND EMPOWERING MEDICAL EDUCATION to underserved, at-risk populations remains a substantial challenge.Wehavemadegreat strides in thediagnosis, treatment, and outcomes in a number of troubling health problems, yet huge gaps remain in populations who are isolated by racial, economic, educational, or geographic characteristics. Friedlander et al realized that classic methods to increase patient awareness of head and neck cancer were failing in New Orleans. They capitalized effectively on preexisting, trusted relationships between the faith community and their leaders and partnered with local churches with their ‘‘Healing Hands across the Divide’’ program. Their team has early data to suggest that the program was well accepted in the community: I am hopeful that this effort can be expanded and provide demonstrable results that are scalable. We are faced with similar challenges in Detroit. Our ‘‘hurricane’’ resulted from the slow decline of the automotive industry, which left an impoverished city with substantial unemployment and high rates of heart disease, obesity, diabetes, and cancer. The faith-based community in our city has remained a constant beacon in these seas of trouble. Churches provide currently many of the services that our city once provided and are a predictable gathering place on any given Sunday and often through the week. Most larger churches in our community also contain a health ministry that provides basic medical services, including screenings and health education.