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.

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The nuclear pore complex (NPC) is an important functional entity of every eukaryotic cell's nuclear membrane. It enables selective transport of materials across the nuclear membrane in an organized and orderly fashion. Substances carried in and out of the nucleus by the NPC include three major groups of molecules: (a) Messenger ribonucleic acid molecules, (b) proteins, and (c) ribonucleoproteins (RNPs). The transport across the nuclear membrane involves adenosine triphosphate hydrolysis in the great majority of cases even though certain guanosine triphosphate-hydrolyzing mechanisms have also been identified. The understanding of the NPC appears crucial to our understanding of certain pathological processes. For example, it has been found that certain human viruses can “trick” our cells into transporting their RNPs into the nucleus using signal peptides similar to the human nuclear-localizing signals. The major challenge of today's research on the NPC resides in identification of over one hundred of its distinct polypeptide units and in determining their functions and interactions. To date, many of the structural proteins involved in the NPC have been identified, but the mechanism of their interactions still remains largely hypothetical. This project discusses the structure and function of the NPC. The following core competencies are addressed in this article: Medical knowledge. Republished with permission from: Stawicki SP, Steffen JM. The nuclear pore complex: A comprehensive review of structure and function. OPUS 12 Scientist 2007;1(2):39-87.

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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 H_A) 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 azygos lobe is a rare anomaly that developmentally arises when the right posterior cardinal vein penetrates the apex of the lung, instead of passing over it, and travels inferiorly taking pleural layers with it to entrap a portion of the right upper lobe. This article reviews the key computed tomography characteristics of azygos lobe, focusing on clinical implications. The following core competencies are addressed in this article: Medical knowledge. Republished with permission from: Wall J, Stawicki SP. Interesting clinical image: The azygos lobe. OPUS 12 Scientist 2009;3(2):28-29.

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Background: Emergency medicine (EM) as a specialty in India is at its infancy. Point-of-care ultrasound (POCUS) is an indispensable tool for the emergency physician (EP). We sought to determine the current experience and resources of POCUS training among EM teaching programs in India. Methods: At a national EM board review course, a survey was carried out among 41 residents from 15 different teaching institutes across seven states of India. The survey consisted of questions pertaining to their experience and knowledge in performing basic and advanced POCUS examinations and its utilization in their department. Results: Most residents (90.2%) were of the opinion that POCUS is an indispensable tool for the EP. All residents had access to an ultrasound (US) machine, with 90.2% having at least one dedicated machine in their department. 12.1% of the residents utilized POCUS less than five times a day while 14.6% reported using US more than twenty times a day. 68.5% of residents identified the major modality of learning POCUS was from a mentor, and about one-third were exclusively dependent on it. The least utilized sources were books and lectures (19%). Extended focused assessment with sonography in trauma (EFAST) was the most frequently performed examination (95%) and was performed with highest level of confidence. Among the advanced examinations, residents knew how to perform and interpret airway (53.7%) and renal sonography (53.7%) the most while they were least familiar with ocular sonography (19%). 70.1% residents reported that POCUS was utilized for facilitating vascular access, 53.7% for nerve blocks, and paracentesis around 19%. Only 46% reported that other departments rely on their findings to make clinical decisions. Conclusion: POCUS was utilized by the residents for different diagnostic examinations and interventions, with the most common being EFAST. The most common learning source of POCUS was from hands-on training by a mentor. There exists a need for guidelines or standardization of POCUS in the EM curriculum to achieve resident competency. The following core competencies are addressed in this article: Interpersonal skills and communication, Medical knowledge, Patient care, Systems-based practice.

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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.

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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.

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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

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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.

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Background: Faculty turnover is a major problem at academic medical institutions. A minority of medical school graduates choose academic careers and those that do have a high rate of attrition. Methods: We conducted an in-depth review of the medical and business literature to determine high-frequency reasons for faculty attrition, and explored what strategies have been suggested or employed to reduce this trend. Results: Medical and business literature demonstrate that faculty morale, perceptions of work-life balance, support from the institution, faculty development, rewards, protected time, relationship with superiors, and role clarity all play a role in faculty decisions to leave an institution. Institutions have shown some success in reducing attrition through recruiting to retain, formal mentorship programs, novel reward programs tied to longevity, faculty development, and attention to faculty professional and personal goals. Conclusions: Academic medical centers should conduct retention analyses to determine commonly cited reasons for attrition at the global and departmental level. Measures to improve retention can be taken at every step of the recruitment, training, and seasoned employee level. Retention efforts are guided and enhanced by open and frequent communication between faculty and administration. The following core competencies are addressed in this article: Professionalism, Practice-based learning and improvement, Systems-based practice, Interpersonal skills and communication

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There are growing problems with the supply of trauma surgeons and/or willingness to participate in trauma care. Solutions proposed include the use of nonsurgeon providers and the development of an acute care surgery model to enhance the attractiveness of training in the field. We propose that immediate modification of clinical operations within trauma centers may address some of these problems and improve patient care and safety. The use of structured shift work models with efficient systems for communication and handoff may improve workforce utilization and vitality both in the near and far term. The following core competencies are addressed in this article: Interpersonal and communication skills, Practice-based learning and improvement, Professionalism, Systems-based practice. Republished with permission from: Grossman MD. Workforce, work hours, and workforce vitality: Toward new models of trauma coverage. OPUS 12 Scientist 2008;2(3):1-2.

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Paragonimiasis is a food-borne parasitic infection that commonly affects humans after ingestion of raw or undercooked crustaceans. The disease is caused by lung flukes of the genus Paragonimus, which is endemic to Southeast Asia. In this report, we describe two cases of paragonimiasis diagnosed in North American immigrants from Southeast Asia. The first patient presented with a 5-year history of hemoptysis. The second presented with a 3-week history of productive cough. Both patients were initially treated with antibiotics for presumed pneumonia. The inciting pathogen was not identified by blood, sputum, or stool analyses. Ultimately, surgical resection was required, leading to the diagnosis of paragonimiasis. In the United States and other nonendemic areas, the diagnosis of paragonimiasis is often delayed due to its rarity. Increased awareness and inclusion in differential diagnoses, especially in patients originating from endemic areas, may prevent diagnostic delay and associated morbidity. The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge, and Patient care.

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Due to the great increase of international travel and emigration, physicians the world over may face serious diagnostic challenges, resulting from the inability to recognize diseases totally alien to their culture, and diseases common to their culture but presenting with previously unseen complications. Over the past 50 years, the frequency of Mycobacterium tuberculosis (MT) infections, arising in the native populations of the United States and other industrialized countries, has been declining. However, the rate of infections in under-developed nations remains at a very high rate. Tuberculosis (TB) can occur in any organ or tissue and can mimic many other diseases. We present the case of a 95-year-old male immigrant from India, with abdominal pain and chronic anemia. Investigation of his abdominal pain revealed a large pancreatic mass with possible hepatic metastases consistent with pancreatic cancer. Fine-needle aspiration biopsy of the mass obtained by endoscopic ultrasound, demonstrated granulomatous inflammation and yielded cultures positive for MT. Antitubercular therapy resulted in progressive resolution of the pancreatic mass and the anemia. The initial clinical impression and radiological findings, in a 95-year-old patient, may well have prompted a harmful decision to opt for comfort care only. This was avoided in our patient by adherence to the strict standard of pursuing a definitive tissue diagnosis for all “masses of unknown origin.” The merits of this case report are in the thorough discussion and illustration of the unusual pathogenesis of TB of the elderly, the imperative of assessing socioeconomic status of patients, and the diagnostic considerations required to evaluate extrapulmonary TB. The following core competencies are addressed in this article: Patient care and Medical knowledge.

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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.

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Introduction: Although the venous collapsibility index (VCI) and central venous pressure (CVP) have been shown to correlate reasonably well, little has been reported on the relationships between VCI and other commonly used hemodynamic variables (i.e., HR, blood pressure). This is a retrospective, post hoc analysis of data from a recently completed 3-year prospective study of VCI in critically ill and injured patients. Materials and Methods: A total of 267 previously recorded data pairs in a group of 82 adults (≥18 to <90 years) patients were included in this analysis. Subsequent correlations were performed between VCI and the following clinical parameters: (a) Heart rate (HR), (b) systolic blood pressure (SBP), (c) diastolic blood pressure (DBP), (d) mean arterial pressure (MAP), (e) pulse pressure, (f) abdominal perfusion pressure (APP or MAP-CVP), (g) positive end-expiratory pressure (PEEP), head-of-bed elevation, and (h) HR-blood pressure index (i.e., HR minus MAP). In addition, correlations between inferior vena cava (IVC) maximum diameter (cm) and demographic variables (age, gender) were performed. Results: Male patients had significantly greater maximum IVC diameters (2.12 ± 0.89 cm) than female patients (1.81 ± 0.61 cm,P< 0.01). We also observed a statistically significant increase in maximum IVC diameter with increasing age, where patients ages 18–44 had mean maximum IVC diameters of 1.81 ± 0.67 and patients ages 45–90 had mean maximum IVC diameters of 2.04 ± 0.78 (P < 0.05). Statistically significant correlations were found between VCI and DBP (R = 0.217,P< 0.03), PEEP (−0.25,P< 0.01), APP (R = 0.23,P< 0.01), and CVP (R = −0.395,P< 0.01). In addition, in patients who were noted to have clinically and/or hemodynamically “discrepant” VCI and CVP measurements, a high VCI (>50%) more accurately correlated to expected SBP and DBP behavior. Conclusions: These preliminary results suggest that DBP may correlate with volume status-based VCI behavior than either SBP or MAP and that VCI may be more accurate in patients experiencing intravascular volume depletion. While these findings are not entirely surprising, further studies are warranted to improve our understanding of the clinical implications and relevance of these findings. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Patil P, Kelly N, Papadimos TJ, Bahner DP, Stawicki SP. Correlations between venous collapsibility and common hemodynamic and ventilatory parameters: A multi-variable assessment. OPUS 12 Scientist 2014;8(1):1-5.

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Background: Internationally, emergency medicine (EM) physicians are vulnerable to both physical and verbal violence. Few studies have examined or compared perceptions and the impacts of workplace violence in India and the United States (US). Objectives: To assess the perceived incidence of workplace violence and its implications on sleep, missed days of work, fear in the workplace, and overall job satisfaction. Materials and Methods: This was an anonymous, prospective, cross-sectional electronic survey of EM residents and physicians. A cohort of physicians in the US was matched to a cohort of physicians in India. Results: Overall, 286 physicians were eligible to participate, 177 responded (98 people from the US and 79 from Indian, for a 62% total response rate). In the US 100% of respondents witnessed verbal violence, whereas only 23% of verbal abuse cases were reported. In India, 89% of respondents witnessed verbal abuse, 46% of cases were reported. Respondents in the US both witnessed and experienced significantly more verbal and physical abuse (P < 0.001). Despite the differences in perceived rates of violence, there were no significant differences between country cohorts regarding the consequences of these incidents. This includes self-reported sleep, missed days of work, and fear of going to the workplace. US respondents were less satisfied with their jobs due to workplace violence as compared to their Indian colleagues (P = 0.041). Conclusion: ED workplace violence is common internationally, underreported, and results in poor job satisfaction, workplace fear, and loss of sleep. The following core competencies are addressed in this article: Patient care, Professionalism, Systems-based practice.

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Background: Burnout is hallmarked by physical and psychological exhaustion, coupled with cynicism and disengagement. Evidence suggests that affected physicians not only suffer personally, but that patient safety and clinical outcomes are also negatively affected. This study aimed to identify potentially remediable risks for burnout among residents enrolled in Canadian general surgery programs. Methods: In this cross-sectional design, a questionnaire was distributed to every general surgery resident in the 15 programs consenting to participate. Questions examined the following five domains: demographics, working patterns, attitudes toward residency, life experiences, and lifestyle/outlook. Respondents' risks of burnout were assessed using the Maslach Burnout Inventory^™. Univariate analysis and then multiple logistic regression were used to assess predictors. Results: A total of 114 completed questionnaires were received (22%). Of these residents, 39 (34%) met the criteria for high burnout risk. Inadequate personal/family time, a personal history of mental health or substance abuse-related issues, and moderately to poorly approachable staff/senior residents were all significantly associated with a high burnout risk (odds ratio [OR] =4.3, 95% confidence interval [CI] =1.6, 11.2, P = 0.003; OR =6.0, 95% CI = 1.6, 21.9, P = 0.007; and OR = 4.6, 95% CI = 1.7, 12.5, P = 0.003 respectively). Predicted high burnout risk probability with none of the above factors was 10%, increasing up to 40%, 75%, and 93% with one, two, or all of these risk factors present respectively. Conclusion: One-third of general surgery residents in Canada are at high burnout risk. Residency programs may have considerable influence over factors associated with this outcome to the benefit of residents, staff, and patients. The following core competencies are addressed in this article: Practice-based learning and improvement, Professionalism, Systems-based practice.

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Academic medical centers (AMCs) are no strangers to operating in a challenging environment; however, the challenges have never been more significant and the future more uncertain than now largely due to the changes affected by the health care reform and the possibility of more changes stemming from the political arena. The looming threat to the triple mission of outstanding clinical care, education, and research can only be successfully thwarted by a shift in the mindset of health-care leadership to better align with winning strategies for a volatile environment. Adapting some of the proven leadership strategies in a business setting may be beneficial in navigating the challenging and changing healthcare arena. Two strategies are highlighted with examples in this review: the adaptation of a “growth” mindset over a “fixed” mindset, and application of compassionate management during challenging times, both of which have been shown to improve the overall financial performance of a company. Integration of these strategies and allocation of resources to professional growth and leadership development can equip health system managers, physicians, staff and trainees with the adaptive tools necessary for meeting the increasing demands and ensuring the continued success of an AMC. With nearly 6000 pathologists and 2200 residents working in an academic setting, an increasing emphasis on leadership development and management tools for pathology professionals is timely. The following core competencies are addressed in this article: Interpersonal and communication skills, Practice-based learning and improvement, Professionalism, Systems-based practice.

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Key points: (a) Polycystic kidney disease (PKD) is one of the most common genetic disorders; (b) There are two main types of PKD– autosomal dominant (most common) and autosomal recessive; (c) Diagnosis of PKD relies on a combination of clinical history, family history, imaging studies (computed tomography, ultrasound) and clinical findings (hematuria, hypertension, proteinuria); (d) Extrarenal manifestations of PKD include hepatic cysts, pancreatic and intestinal cysts, colonic diverticula, inguinal and abdominal wall hernias, valvular heart disorders, and cerebral aneurysms; (e) Treatment is centered on ameliorating symptoms and providing supportive care– therapy consists of adequate analgesia for pain symptoms, antibiotics for urinary tract infections, antihypertensive medications, renal supportive therapy; (f) Surgical indications include surgical decompression of large cysts and renal transplantation for end-stage renal failure. The following core competencies are addressed in this article: Medical knowledge and patient care. Republished with permission from: Stawicki SP, Lombardo G. Polycystic kidney disease. OPUS 12 Scientist 2008;2(1):17-20.

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Retroperitoneal sarcomas (RS) are malignant tumors arising from mesenchymal cells, which are usually located in adipose, muscle, or connective tissue. RSs represent approximately 15% of all sarcomas and approximately 33–55% of all retroperitoneal tumors. The most common variants of RS include liposarcoma (40%), leiomyosarcoma (30%), and malignant fibrous histiocytoma (<10%). This article reviews the most important clinical characteristics of RSs, focusing on high-yield facts frequently encountered on standardized exams. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Stawicki SP. Retroperitoneal sarcomas. OPUS 12 Scientist 2007;1(1):17.

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Key points: (a) Reexpansion pulmonary edema-RxPE– is a rare form of acute lung injury, with an incidence of approximately 1% following evacuation of a pneumothorax; (b) RxPE usually follows rapid reinflation of collapsed lung parenchyma; (c) The most common factor associated with RxPE is the duration of lung collapse– more than 3 days seems to be the critical amount of time; (d) The pathophysiologic changes associated with RxPE are complex and not yet fully understood; (e) The pathologic process results from a combination of rapid pulmonary reexpansion with concurrent mechanical alveolar injury, decrease in surfactant and regional lung tissue hypoxemia, inflammatory cell migration and release of inflammatory mediators, and the resulting changes in capillary-alveolar barrier occurring concurrently with increased capillary/hydrostatic pressures; (f) Clinical manifestations of RxPE vary from minimal symptoms to life-threatening hypoxia and cardio-respiratory collapse; (g) The patient may experience dyspnea, thoracic pain, cough with or without pink/foamy sputum, cyanosis, rales and stertors on auscultation. Other clinical symptoms may include fever, nausea, vomiting, tachycardia, and hypotension; (h) The symptoms of RxPE usually appear within the first two hours following pulmonary reexpansion, but may be delayed by as many as 24-48 h; (i) RxPE usually lasts clinically for as long as 1-2 days, but may take anywhere from 5 to 7 days to resolve; (j) Critical care practitioners should be familiar with the most common factors involved in the pathogenesis of RxPE; (k) The knowledge of these predisposing factors and the ability to effectively treat RxPE are important to prevention and treatment of this potentially fatal condition. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Stawicki SP, Sarani B, Braslow BM. Reexpansion pulmonary edema. OPUS 12 Scientist2008;2(2):29-31.

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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.

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