Timothy Udoji

Evaluating Simulation-Based ACLS Education on Patient Outcomes: A Randomized, Controlled Pilot Study

BACKGROUND Simulation training is widely accepted as an effective teaching tool, especially for dealing with high-risk situations. OBJECTIVE We assessed whether standardized, simulation-based advanced cardiac life support (ACLS) training improved performance in managing simulated and actual cardiac arrests. METHODS A total of 103 second- and third-year internal medicine residents were randomized to 2 groups. The first group underwent conventional ACLS training. The second group underwent two 2 1/2-hour sessions of standardized simulation ACLS teaching. The groups were assessed by evaluators blinded to their assignment during in-hospital monthly mock codes and actual inpatient code sheets at 3 large academic hospitals. Primary outcomes were time to initiation of cardiopulmonary resuscitation, time to administration of first epinephrine/vasopressin, time to delivery of first defibrillation, and adherence to American Heart Association guidelines. RESULTS There were no differences in primary outcomes among the study arms and hospital sites. During 21 mock codes, the most common error was misidentification of the initial rhythm (67% [6 of 9] and 58% [7 of 12] control and simulation arms, respectively, P  =  .70). There were no differences in primary outcome among groups in 147 actual inpatient codes. CONCLUSIONS This blinded, randomized study found no effect on primary outcomes. A notable finding was the percentage of internal medicine residents who misidentified cardiac arrest rhythms.

Mediastinal and Hilar Lymph Node Measurements. Comparison of Multidetector-Row Computed Tomography and Endobronchial Ultrasound

RATIONALE Multidetector-row chest computed tomography scan is a common initial imaging modality and endobronchial ultrasound is a minimally invasive diagnostic tool used to evaluate enlarged lymph nodes, but comparisons of imaging results are lacking. OBJECTIVES To determine the size of thoracic lymph nodes and the strength of agreement between each measurement from coronal plane computed tomography and static endobronchial ultrasound images. METHODS A retrospective review of consecutive patients who underwent endobronchial ultrasound-transbronchial needle aspiration of their lymph nodes because of clinical suspicion of benign or malignant thoracic disease. MEASUREMENTS AND MAIN RESULTS One hundred and twenty-four lymph nodes from the mediastinal (74.2%) and hilar (25.8%) stations were measured in 59 patients (mean age, 64.5 yr; 33 males). The mean (standard deviation) short-axis diameter on computed tomography was 14.1 (6.7) mm compared with 12.6 (6.6) mm on endobronchial ultrasound. Benign lymph nodes (n = 42) were larger on computed tomography than on endobronchial ultrasound (14.1 [6.2] vs. 11.5 [6.2] mm). Malignant lymph nodes (n = 35) were larger on endobronchial ultrasound than on computed tomography (17.3 [6.4] vs. 16.2 [6.7] mm). Sixty-five percent of the lymph nodes that were initially interpreted as not enlarged on axial computed tomography images measured greater than 10 mm on each imaging modality (12.5 [5.9] mm on computed tomography and 10.5 [5.6] mm on endobronchial ultrasound) and 24% of the sampled lymph nodes from this group contained malignant cells. Random-effects maximal likelihood linear regression showed a statistically significant difference between endobronchial ultrasound and the computed tomography method for measuring short-axis diameter in all 124 lymph nodes. There was a weak agreement (intraclass correlation, rho: 0.44 [95% confidence interval, 0.31-0.59]) between short-axis diameter measurements from each imaging modality. CONCLUSIONS Our single-center study shows that there was poor correlation between computed tomography and endobronchial ultrasound for the measurement of mediastinal and hilar lymph nodes. Malignant cells were recovered by ultrasound-guided needle aspiration from a substantial fraction of lymph nodes that were initially interpreted as normal in size. If these findings are confirmed, new criteria may be needed for lymph node measurement on computed tomography that will guide selection of lymph nodes for endobronchial ultrasound-transbronchial needle aspiration.

The use of transtracheal oxygen therapy in the management of severe hepatopulmonary syndrome after liver transplantation.

Hepatopulmonary syndrome (HPS) is a unique form of hypoxemia found in patients who have chronic liver disease. The definitive treatment for HPS is liver transplantation (LT), with resolution of hypoxemia occurring weeks to months after LT. Because there has been an increase in the use of LT to treat severe HPS (PaO2 ≤ 50 mm Hg), alternatives to oxygen administration via nasal cannula (NC) or face mask must be examined to facilitate early postoperative mobilization and to minimize postoperative pulmonary complications. Transtracheal oxygen (TTO) therapy is a practical alternative that has been shown to improve oxygen requirements, facilitate patient mobility, and improve exercise tolerance in advanced lung disease. In this case series, we describe the use of TTO in the management of hypoxemia associated with severe HPS after LT. A transition from NC to TTO resulted in a significant reduction in oxygen requirements, early postoperative mobilization and discharge from the hospital, and a subsequent expedited liberation from supplemental oxygen. This case series emphasizes the potential utility of TTO therapy as an alternative to conventional oxygen delivery modalities in the management of severe HPS after LT.

Severe mitral regurgitation unmasked after bilateral lung transplantation.

A 33-year-old female patient with advanced idiopathic pulmonary artery hypertension underwent bilateral lung transplantation. The postsurgical course was complicated by prolonged mechanical ventilation and acute hypoxemia with recurrent episodes of pulmonary edema. An echocardiogram revealed improved right-sided pressures along with a dilated left atrium, a structurally normal mitral valve, and a new posterior-oriented severe mitral regurgitation. The patients condition improved after treatment with arterial vasodilators and diuretics, and she has remained in World Health Organization functional class I after almost 36 months of follow-up. We hypothesize that cardiac ventricle remodeling and a geometric change in mitral valve apparatus after transplantation led to the hemodynamic changes and recurrent pulmonary edema seen in our patient. Our case is, to our knowledge, the second report of severe valvular regurgitation in a structurally normal mitral valve apparatus in the postoperative period and the first of a patient to be treated without valve replacement.

Dyspnea in a patient with Mounier-Kuhn syndrome.

Poorly differentiated non-small cell lung carcinoma with a component of sarcoma-like (spindle and/or giant cells) or sarcoma (malignant bone, cartilage, or skeletal muscle) cells are called pleomorphic carcinoma. These carcinoma represent one of the 5 subtypes of rare pulmonary malignancies collectively classified as sarcomatoid carcinoma by the World Health Organization histologic classification of lung tumors. The pathogenesis of sarcomatoid carcinoma remains unclear, and treatment of this malignant tumor is less defined. Very few cases of sarcomatoid carcinoma involving the upper respiratory tract have been reported in the literature. We report here an atypical presentation and location of this tumor (in the trachea), causing obstruction with a positional ball-valve effect, in a patient with tracheobronchomegaly (Mounier-Kuhn syndrome). In addition, we discuss the recurrent nature of the disease and the potential therapeutic difficulties.