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Scrutinizing the evidence linking hypokalemia and ileus: A commentary on fact and dogma
William Matthew Brigode, Christian Jones, Daniel E Vazquez, David C Evans
July-December 2015, 1(1):21-26
Low serum potassium has been linked to classic signs and symptoms including mental status changes, muscular dysfunction and paralysis, and cardiac arrhythmias. Frequently, it has been listed as a cause for paralytic ileus, and correcting electrolyte anomalies is one of the first steps in treatment of a patient with nonfunctioning bowels. However, our review of the literature does not support a clear causative link. Older studies cite potassium as one of the many factors to optimize to regain bowl function, while newer studies do not support hypokalemia as a cause of ileus. Current treatment of ileus supports focusing on reversal of the effect of opiates on the gut, while electrolyte therapeutic goals are directed to prevent complications outside of the gastrointestinal (GI) tract. We review the cellular physiology and clinical data to elucidate the nature of the link between low potassium values and its impact on GI motility. Patients: Patients with hypokalemia and ileus. Intervention: Potassium repletion. Comparison: Patients with normal potassium values. Outcomes: Resolution of ileus. Population, intervention, comparator, and outcomes questions: Does low serum potassium cause intestinal ileus, and will correction of this deficit correct the intestinal paralysis?. The following core competencies are addressed in this article: Practice-based learning and improvement of medical knowledge. This article addresses the evidence linking hypokalemia and ileus to improve medical knowledge and enable physicians to put this evidence into practice.
  7,910 106 -
Classic brown recluse spider bite
Mark William Fegley, Rodrigo Duarte-Chavez, Lauren E Stone, Sudip Nanda
July-December 2016, 2(2):256-259
A 58-year-old female presented with leg paresthesia and rash. On presentation, the rash was most consistent with cellulitis and cephalexin was started. The next day vesicles appeared which were presumed to be shingles and acyclovir was started. They evolved into a fully necrotic lesion on day 4 and had the classic presentation of a brown recluse spider bite. Bite marks were missed at presentation. Brown recluse spider bites are commonly misdiagnosed 80% of the time. Brown recluse venom contains a variety of toxins which can lead to skin necrosis (37% of patients) that occurs via an unknown mechanism dependent on host neutrophils. Skin changes progress over 12–36 h and necrosis develops within several days. Treatment recommendations call for exclusion of other diagnoses and conservative management with local wound care, tetanus prophylaxis, and debridement. Other forms of treatment should be avoided. Our patient was treated with a skin graft with good results. The following core competencies are addressed in this article: Patient care and medical knowledge.
  5,262 15 -
Retained surgical items: Building on cumulative experience
Brett Styskel, Brian Wernick, Ronnie N Mubang, Steven M Falowski, Thomas J Papadimos, Stanislaw P Stawicki
January-June 2016, 2(1):5-21
Retained surgical items (RSIs) are much dreaded, preventable complications associated with surgical and other invasive procedures. Despite much effort going into eliminating these “never events” and the associated heavy burden for patients, providers, and institutions, RSIs continue to occur. This manuscript reviews fundamental concepts related to RSI, including risk factors, prevention strategies, technology-assisted detection, team strategies, and pertinent safety education. In addition, we performed a secondary review of a database of all published case reports and series of RSI between 1909 and 2015, focusing on clinical presentation, symptomatology, morbidity, diagnostic workup, pathology findings, and temporal characteristics. Despite a vast body of knowledge regarding RSIs, more needs to be done to help further reduce and prevent these occurrences. The following core competencies are addressed in this article: Patient care, Medical knowledge, Practice based learning and improvement, Systems based practice, Professionalism, and Interpersonal skills and communication
  4,435 56 1
Focus on emotional intelligence in medical education: From problem awareness to system-based solutions
Reina Uchino, Franz Yanagawa, Bob Weigand, James P Orlando, Thomas J Tachovsky, Kathleen A Dave, Stanislaw P Stawicki
July-December 2015, 1(1):9-20
Objective: To review emotional intelligence (EI) literature in the context of how its application can help mediate various stressors among medical students, physicians-in-training, and faculty. Also, discussed are potential barriers to why EI-based programs face challenges to full implementation in medical education. Literature Search: MEDLINE, PsychINFO, EMBASE, Google Scholar, and Web of Science were searched for English language articles using various combinations of the following terms: EI, medical students, medical education, graduate medical education, trainees (including intern, resident, and residency), practitioners, and physicians. Electronic publications and printed books referenced by primary sources were also included. Results: Although there is increasing evidence for EI implementation being favorably associated with physician wellness, decreasing burnout, building better physician-patient relationships, and even better patient outcomes, there has so far not been a large scale movement to integrate EI into medical school curricula. The main barriers to wider implementation of EI are general lack of awareness, insufficient time and resources, and paucity of qualified faculty. Conclusions: Despite a number of associated potential benefits, EI has been facing various implementation hurdles in the medical education setting. Increasing awareness of EI and its benefits could help medical schools and residency programs around the globe to more actively engage in the implementation of EI training into medical school and residency curricula. We expect that such interventions would have several desirable outcomes, including improved overall physician wellness, enhanced patient experience, and perhaps even improved patient outcomes. The following core competencies are addressed in this article: Practice-based Learning and Improvement, Patient care, Professionalism, Interpersonal and communication skills, Systems-based practice.
  3,141 166 -
Neuromonitoring protocol for spinal cord stimulator cases with case descriptions
Steven Falowski, Andres Dianna
July-December 2016, 2(2):132-144
Spinal cord stimulation (SCS) relies on the ability to create an overlap of paresthesia on the painful regions. Electrode implantation has historically been performed with awake intraoperative testing to allow the patient to report on the device-induced paresthesia. More recently, the use of neuromonitoring has come into favor and can be used for SCS placement, while the patient remains fully anesthetized throughout the surgery. This is a critical evaluation of the neuromonitoring technique and protocol with an in-depth description of neuromonitoring for SCS placement using electro-myography (EMG) responses in both cervical and thoracic electrode placement. There is an explanation for the interpretation of the EMG responses, as well as case reports of two patients. Neuromonitoring is used to determine myotomal coverage, as a marker that corresponds with dermatomal coverage. This article demonstrates some of the critical steps for both the surgeon and neuromonitoring group to implement this technique, as well as the clinical results of paresthesia coverage in patients. This protocol can be utilized in implementing neuromonitoring into a practice for those implanting SCS systems. The following core competencies are addressed in this article: Medical knowledge, patient care, practice-based learning and improvement, system-based practice, interpersonal and communication skills. This article addresses the gap in knowledge base to implement an approach to improve patient care and outcome.
  2,502 35 -
Brain drain in academic medicine: Dealing with personnel departures and loss of talent
Brian Wernick, Thomas R Wojda, Alexander Wallner, Franz Yanagawa, Michael S Firstenberg, Thomas J Papadimos, Stanislaw P Stawicki
January-June 2016, 2(1):68-77
The phenomenon of “brain drain,” (BD) or the unanticipated and significant loss of skilled people and the talent they represent via voluntary turnover, continues to be a significant problem across many academic medical centers. This BD is a result of a multifactorial interplay between personal, professional, institutional, peer-driven, and socioeconomic factors and affects mainly academic healthcare organizations characterized by a specific set of leadership, economic, and competitive preconditions. Institutional impact of BD, both financial and nonfinancial, can be profound and is often underappreciated. Financial considerations of BD include loss of clinical and non-clinical income, contraction of institutional expertise, severance and recruitment expenses, as well as costs of onboarding new faculty. This article focuses on how to identify risk factors for BD at both institutional and personnel levels. Proposed steps for prevention and early intervention are outlined. The following core competencies are addressed in this article: Professionalism, Practice-based learning and improvement, Systems-based practice, Interpersonal skills, and Communication.
  2,469 43 -
Type I, II, and III statistical errors: A brief overview
Parampreet Kaur, Jill Stoltzfus
Jul-Dec 2017, 3(2):268-270
As a key component of scientific research, hypothesis testing incorporates a null hypothesis (H0) of no difference in a larger population and an alternative hypothesis (H1or HA) that becomes true when the null hypothesis is shown to be false. Two potential types of statistical error are Type I error (α, or level of significance), when one falsely rejects a null hypothesis that is true, and Type II error (β), when one fails to reject a null hypothesis that is false. To reduce Type I error, one should decrease the pre-determined level of statistical significance. To decrease Type II error, one should increase the sample size in order to detect an effect size of interest with adequate statistical power. Reducing Type I error tends to increase Type II error, and vice versa. Type III error, although rare, occurs when one correctly rejects the null hypothesis of no difference, but does so for the wrong reason. The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge.
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The shortage of psychiatrists and other mental health providers: Causes, current state, and potential solutions
Tracy Butryn, Leah Bryant, Christine Marchionni, Farhad Sholevar
January-June 2017, 3(1):5-9
  2,298 26 -
Analysis of repeated measures data: A quick primer
Jill C Stoltzfus
January-June 2016, 2(1):95-97
When analyzing data for dependent groups (e.g., before and after intervention), one use repeated measures statistical tests that account for the correlated observations. For normally distributed data measured on a continuous/interval scale (e.g., fasting glucose) with only two points of measurement (e.g., before and after), one would conduct a paired t-test. For more than two measurement points (e.g., baseline, 3 months, 6 months), repeated measures analysis of variance is appropriate. For skewed continuous/interval data (e.g., body mass index in the general population), or ordinal data (e.g., visual analog pain scores), one could conduct a Wilcoxon signed-rank test (for two measurement points) or a Friedman's test (for more than two measurement points). The following core competencies are addressed in this article: Medical knowledge.
  2,183 40 -
Finger nail changes: A red flag for connective tissue disease
Mark W Fegley, Rodrigo Duarte-Chavez, Whitney Fegley, Lauren E Stone, Amitoj Singh, Sudip Nanda
January-June 2017, 3(1):197-201
We report a 68-year-old female who presented to the cardiology clinic with ventricular tachycardia and specific finger nail abnormalities including proximal capillary loops and proximal and periungual erythema. The patient had multiple underlying connective tissue disorders and pulmonary fibrosis. Finger nail changes are highly specific and are an indication for all healthcare providers that connective tissue diseases (CTDs) are likely underlying. We review the clinical signs and symptoms, review diagnostic criteria, and further testing to evaluate for CTDs. The following core competencies are addressed in this article: Patient care, Medical knowledge.
  2,019 15 -
Advanced practitioner-driven critical care outreach to reduce intensive care unit readmission mortality
Niels Douglas Martin, Michael A Pisa, Tara Ann Collins, Matthew P Robertson, Corinna P Sicoutris, Naveena Bushan, Jason Saucier, Amanda Martin, Patrick M Reilly, Meghan Lane-Fall, Benjamin Kohl
July-December 2015, 1(1):3-8
Objectives: Intensive care unit (ICU) readmission is associated with poorer outcomes as compared to primary admissions. Recognizing new or recurrent critical care issues on the wards postICU discharge may improve outcomes, especially in those subsequently requiring readmission. Herein, we describe and evaluate a pilot surgical critical care outreach initiative to reduce mortality in patients ultimately requiring ICU readmission. Methods: Each patient discharged from the ICU was visited within 48 h by a Critical Care Advanced practitioner who examined the patient, reviewed the chart, recent laboratory results, and orders, and then communicated any concerns to the primary service. Patient demographics, outreach issues identified, and severity of issues were recorded prospectively. Retrospectively, patient outcomes were assessed including the need and timing of any ICU readmission and mortality both before and after outreach implementation. Results: Pre and postoutreach readmission rates were 2.41% (37/1534) versus 3.54% (54/1524), respectively (P = 0.07). Mortality rates before and after outreach were 5.08% (n = 78) versus 5.64% (n = 86) overall (P = 0.052) and 18.9% (n = 7) versus 9.25% (n = 5) for readmissions (P = 0.21), respectively. Conclusions: Critical care outreach postICU discharge did not decrease readmission mortality in this pilot study. Further studies are required to evaluate its effects on not only readmission mortality but also readmission rates and timing along with the incident of subsequent ICU complications. The following core competencies are addressed in this article: Patient care, Systems based practice, Communication.
  1,910 98 -
The importance of emotional intelligence to leadership in an Academic Health Center
Thomas J Papadimos, Angela C Sipes, Michael R Lyaker, Claire V Murphy, Areti Tsavoussis, Scott M Pappada
January-June 2016, 2(1):57-67
Emotional Intelligence (EI) was first defined in the 1990s and was quickly adopted by the business community. The role of EI in leadership has come to the forefront and is now recognized as the most important trait/skill set that a leader can possess. In the next decade, there will be many challenges to the leaders of Academic Health Centers (AHCs). Understanding the role of EI and the implementation of its precepts in the personal culture of leaders and the organization will be extremely important. EI theory, its tools for assessment, its studies for validation, and its use for the development of professional curriculum for individuals and organizations will continue to evolve over time. Here, we will define EI and explain its origins and its importance to the success of AHCs. Furthermore, its importance to medical students, residents, and subordinates, its measurement, its juxtaposition to nature versus nurture, and what role simulation may play in increasing the EI skills of members of AHCs will also be addressed. The following core competencies are addressed in this article: Core competencies addressed include systems-based practice, Interpersonal and communications skills, and Professionalism.
  1,944 52 1
What's New in Academic Medicine? Retained surgical items: Is “zero incidence” achievable?
Michelle C Nguyen, Susan D Moffatt-Bruce
January-June 2016, 2(1):1-4
  1,893 49 -
Diagnosis of Achilles tendon rupture with ultrasound in the emergency department setting
Jeff Peck, Karen E Gustafson, David P Bahner
May 2017, 3(3):205-207
The authors describe a case of a middle-aged male with ruptured Achilles tendon sustained while jumping. Bedside ultrasound was instrumental in making the diagnosis. The following core competencies are addressed in this article: Medical knowledge, Patient care. Reprinted with permission from: Peck J, Gustafson KE, Bahner DP. Bedside sonography primer: diagnosis of Achilles tendon rupture with ultrasound in the emergency department. OPUS 12 Scientist 2011;5(2):17-18.
  1,904 17 -
Mechanical ventilation: Weaning and extubation
Stanislaw P Stawicki
May 2017, 3(3):67-71
Discontinuation of mechanical ventilatory support represents a milestone in the progression to patient recovery in the Intensive Care Unit (ICU). Despite advances in mechanical ventilation and respiratory support, the science of determining if the patient is ready for extubation is still very imprecise. The goal of this article is to summarize key developments in this important clinical area. The following core competencies are addressed in this article: Medical knowledge and patient care. Republished with permission from: Stawicki SP. ICU Corner – Mechanical ventilation: Weaning and extubation. OPUS 12 Scientist 2007;1(2):13-16.
  1,771 18 -
A case of autopneumonectomy without any symptoms
Trilok Chand, Avdhesh Bansal, Vaibhav Shankar
January-June 2016, 2(1):115-118
Autopneumonectomy simply describes the autolysis or almost complete destruction of the lung tissue without any surgical removal of the lung. This is not a common occurrence but is sometimes observed in areas where tuberculosis (TB) is endemic. The patients are usually diagnosed when they come to the hospital either with complications related to autopneumonectomy or a postpneumonectomy-like syndrome. Rarely, these patients remain asymptomatic until late age. Our case was an elderly female with an abnormal chest X-ray, who was referred to us for respiratory clearance for the surgical fixation of the fracture of the neck of femur. The history revealed that she had some chest infection and/or pulmonary TB in childhood that explained the autopneumonectomy. The patient underwent a successful surgery and was discharged with advice to follow-up for any chest complaints in the future. The following core competencies are addressed in this article: Patient care, Medical knowledge.
  1,657 33 -
Student's t-test for independent samples
Jill C Stoltzfus
July-December 2015, 1(1):27-28
When analyzing data for two independent groups (e.g., males vs. females), the Student's t-test is commonly used for normally distributed data measured on a continuous/interval scale (e.g., body mass index). The mathematical formula for the Student's t-test includes the mean between-group difference in the numerator and between-group variability in the denominator. The following core competencies are addressed in this article: Medical knowledge.
  1,584 86 -
Maggot debridement therapy: A practical review
Ashley Jordan, Neeraj Khiyani, Steven R Bowers, John J Lukaszczyk, Stanislaw P Stawicki
January-April 2018, 4(1):21-34
Maggot debridement therapy (MDT) has a long and well-documented history. Once a popular wound care treatment, especially prior to the discovery of antibiotics, modern dressings or debridement techniques, MDT fell out of favor after the 1940s. With the increasing prevalence of chronic medical conditions and associated complex and difficult-to-treat wounds, new approaches have become necessary to address emerging issues such as antibiotic resistance, bacterial biofilm persistence and the high cost of advanced wound therapies. The constant search for a dressing and/or medical device that will control pain, remove bacteria/biofilm, and selectively debride necrotic wound material, all while promoting the growth of healthy new tissue, remains elusive. On review of the current literature, MDT comes very close to addressing all of the previously mentioned factors, while at the same time remaining cost-effective. Complications of MDT are rare and side effects are minimal. If patients and providers can look past the obvious anxiety associated with the management and presence of larvae, they will quickly see the benefits of this underutilized modality for healing multiple types of wounds. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement.
  1,642 11 -
Establishing an instrumented training environment for simulation-based training of health care providers: An initial proof of concept
Scott M Pappada, Thomas John Papadimos, Jonathan A Lipps, John J Feeney, Kevin T Durkee, Scott M Galster, Scott R Winfield, Sheryl A Pfeil, Sujatha P Bhandary, Karina Castellon-Larios, Nicoleta Stoicea, Susan D Moffatt-Bruce
January-June 2016, 2(1):32-40
Objective: Several decades of armed conflict at a time of incredible advances in medicine have led to an acknowledgment of the importance of cognitive workload and environmental stress in both war and the health care sector. Recent advances in portable neurophysiological monitoring technologies allow for the continuous real-time measurement and acquisition of key neurophysiological signals that can be leveraged to provide high-resolution temporal data indicative of rapid changes in functional state, (i.e., cognitive workload, stress, and fatigue). Here, we present recent coordinated proof of concept pilot project between private industry, the health sciences, and the USA government where a paper-based self-reporting of workload National Aeronautics and Space Administration Task Load Index Scale (NASA TLX) was successfully converted to a real-time objective measure through an automated cognitive load assessment for medical staff training and evaluation (ACLAMATE). Methods: These real-time objective measures were derived exclusively through the processing and modeling of neurophysiological data. This endeavor involved health care education and training with real-time feedback during high fidelity simulations through the use of this artificial modeling and measurement approach supported by Aptima Corporation's FuSE2, SPOTLITE, and PM Engine technologies. Results: Self-reported NASA TLX workload indicators were converted to measurable outputs through the development of a machine learning-based modeling approach. Workload measurements generated by this modeling approach were represented as a NASA TLX anchored scale of 0–100 and were displayed on a computer screen numerically and visually as individual outputs and as a consolidated team output. Conclusions: Cognitive workloads for individuals and teams can be modeled through use of feed forward back-propagating neural networks thereby allowing healthcare systems to measure performance, stress, and cognitive workload in order to enhance patient safety, staff education, and overall quality of patient care. The following core competencies are addressed in this article: Medical Knowledge, Interpersonal Skills, Patient Care, and Professionalism.
  1,596 56 2
Gastrointestinal fistulae
Stanislaw P Stawicki, Benjamin M Braslow
May 2017, 3(3):77-81
Key points: (a) Gastrointestinal fistulae (GIF) continue to be associated with high morbidity and mortality; (b) Approximately 85% to 90% of GIF result from surgical procedures; (c) Spontaneous GIF (10% to 15%) most commonly result from inflammatory bowel disease, malignancy, and infection (i.e., diverticulitis); (d) Fistula classification and natural behavior are discussed; followed by (e) Discussion of diagnostic and treatment principles, as well as special issues encountered in GIF management. The following core competencies are addressed in this article: Medical knowledge and patient care. Republished with permission from: Stawicki SP, Braslow BM. Gastrointestinal fistulae. OPUS 12 Scientist 2008;2(1):13-16.
  1,627 15 -
Bland–Altman plot: A brief overview
Parampreet Kaur, Jill C Stoltzfus
January-June 2017, 3(1):110-111
In healthcare research, it is common to compare two methods of measurement to determine the overall degree of agreement. The Bland–Altman (BA) plot is an alternative to traditional correlational analyses. The BA plot portrays the agreement graphically by creating statistical limits of agreement using the mean and standard deviation of the differences between two measurements. The difference (Test #1 − Test #2) is constructed on the vertical axis while the mean ([Test #1 + Test #2]/2) is depicted on the horizontal axis. Within this plot, one can detect bias between the mean differences, as well as estimate an agreement interval. If the data points are normally distributed, 95% of differences will lie between the limits, but smaller sample sizes may be unreliable for estimating larger population parameters. Although nonparametric methods can estimate limits of agreement with nonnormally distributed data, they may be less reliable than logarithmically transforming the data before creating the plot. The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge.
  1,616 16 -
Isolated acute traumatic aortic injury following cardiopulmonary resuscitation with excessively forceful chest compressions
Mark W Fegley, Ellen A Redstone, Amitoj Singh, Sahil Agrawal, Jamshid Shirani, Sudip Nanda
July-December 2015, 1(1):29-31
We report a rare cause of isolated acute traumatic aortic injury in a 58-year-old woman with a body mass index (BMI) of 19.4, following cardiopulmonary resuscitation (CPR). Our case is unique in that CPR was performed by a single CPR provider, no significant trauma occurred with the preceding syncope, and aortic injury occurred in isolation without fractures or other traumatic injury. Healthcare providers need to be aware that although chest compression of at least 2 inches depth is needed for effective CPR, the force required to achieve this compression is much less in an individual with a BMI of around 20 as opposed to a BMI of 40. Excessive chest compression can lead to acute traumatic aortic injury. We review appropriate resuscitation and chest compression depth, CPR associated injuries including aortic injuries and mechanisms of acute traumatic aortic injury. The following core competencies are addressed in this article: Patient care and medical knowledge.
  1,477 81 -
Missed traumatic injuries: A synopsis
Stanislaw P Stawicki, David E Lindsey
May 2017, 3(3):13-23
The ultimate goal in trauma resuscitation is to promptly identify and treat all injuries. Despite clinical and technological advances in the diagnosis and treatment of trauma patients, missed injuries continue to significantly affect modern trauma services. Delayed diagnosis and missed injuries have the potential to exacerbate the severity of the initial insult, and may result in permanent disability or even mortality. Moreover, missed injuries add significantly to the length of hospitalization and overall costs of trauma patient care. This article will discuss the common themes associated with missed injuries, and will highlight steps that practitioners can take to minimize delays in diagnosis and to reduce the number of missed injuries. This article begins with basic definitions, followed by a discussion of literature pertaining to, and factors associated with, missed injuries. We will then focus on specific mechanisms and injury patterns, as well as the corresponding injury-specific diagnostic and treatment pitfalls that have to be considered in order to avoid missed injuries. The following core competencies are addressed in this article: Interpersonal and communication skills, Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice. Republished with permission from: Stawicki SP, Lindsey DE. Trauma Corner – Missed traumatic injuries: A synopsis. OPUS 12 Scientist 2009;3(2):35-43.
  1,488 16 -
Hypoplastic left anterior descending coronary artery as the cause of inducible myocardial ischemia in a 46-year-old man
Yuba Acharya, Lakshmi H Chebrolu, Jamshid Shirani
January-June 2016, 2(1):112-114
Hypoplasia of the left anterior descending (LAD) coronary artery in the absence of other congenital cardiac anomalies is quite rare and presents a real therapeutic challenge. Few cases of this type coronary anomaly have been reported in children and young adults. We present a middle-aged man with clinical, electrocardiographic, and dobutamine stress echocardiographic evidence of myocardial ischemia caused by a hypoplastic distal LAD coronary artery originating from a septal perforator. Diagnostic and therapeutic challenges posed by this rare condition are discussed. The following core competencies are addressed in this article: Medical knowledge, Patient care
  1,461 39 -
What's new in academic medicine? Blockchain technology in health-care: Bigger, better, fairer, faster, and leaner
Stanislaw P Stawicki, Michael S Firstenberg, Thomas J Papadimos
January-April 2018, 4(1):1-11
  1,481 9 -