Scholarly Works, Virginia Tech Carilion School of Medicine (VTCSOM)

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Use of Patient-Reported Outcome Measures to Assess the Effectiveness of Hybrid Psychiatric Visits
O'Brien, Virginia C.; Kablinger, Anita S.; Ko, Hayoung; Jones, Sydney B.; McNamara, Robert S.; Phenes, Ashlie R.; Hankey, Maria Stack; Gatto, Alyssa J.; Tenzer, Martha M.; Sharp, Hunter D.; Cooper, Lee D. (American Psychiatric Association, 2024-06-12)
Objective: Little empirical evidence exists to support the effectiveness of hybrid psychiatric care, defined as care delivered through a combination of telephone, videoconferencing, and in-person visits. The authors aimed to investigate the effectiveness of hybrid psychiatric care compared with outpatient waitlist groups, assessed with patient-reported outcome measures (PROMs). Method: Participants were recruited from an adult psychiatry clinic waitlist on which the most common primary diagnoses were unipolar depression, generalized anxiety disorder, and bipolar disorder. Patients (N=148) were randomly assigned to one of two waitlist groups that completed PROMs once or monthly before treatment initiation. PROMs were used to assess symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), and daily psychological functioning (Brief Adjustment Scale-6 [BASE-6]). Patient measures were summarized descriptively with means, medians, and SDs and then compared by using the Kruskal-Wallis test; associated effect sizes were calculated. PROM scores for patients who received hybrid psychiatric treatment during a different period (N=272) were compared with scores of the waitlist groups. Results: PROM assessments of patients who engaged in hybrid care indicated significant improvements in symptom severity compared with the waitlist groups, regardless of the number of PROMs completed while patients were on the waitlist. Between the hybrid care and waitlist groups, the effect size for the PHQ-9 score was moderate (d=0.66); effect sizes were small for the GAD-7 (d=0.46) and BASE-6 (d=0.45) scores. Conclusions: The findings indicate the clinical effectiveness of hybrid care and that PROMs can be used to assess this effectiveness.
Psychiatric comorbidities in children with conduct disorder: a descriptive analysis of real-world data
Brown, Tashalee R.; Kablinger, Anita S.; Trestman, Robert L.; Bath, Eraka; Rogers, Cynthia; Lin, Binx Yezhe; Xu, Kevin Young (BMJ, 2024-04-18)
Septic arthritis due to Nocardia: Case report and literature review
Fazili, Tasaduq; Bansal, Ekta N.; Garner, Dorothy; Bajwa, Vijender; Vasudeva, Shikha (Elsevier, 2022-02-13)
Nocardia is an uncommon cause of septic arthritis. We found only 37 cases reported in the literature thus far. Amongst these, only five involved prosthetic joints. Three cases were caused by N. nova and one each by N. farcinica and asteroides. Septic arthritis due to Nocardia has a favorable outcome with a combination of surgical debridement and prolonged antimicrobial therapy of three to six months. For prosthetic joint infections, removal of hardware seems to carry a better prognosis. Trimethoprim-sulfamethoxazole continues to remain the drug of choice.
Alanyl-glutamine Supplementation for Clostridioides difficile Infection Treatment (ACT): A double-blind randomized controlled trial
Warren, Cirle A.; Shin, Jae Hyun; Bansal, Ekta N.; Costa, Deiziane V. D. S.; Wang, Xin Qun; Wu, Martin; Swann, Jonathan R.; Behm, Brian W.; Targonski, Paul V.; Archbald-Pannone, Laurie (BMJ Journals, 2023-07-19)
Introduction: Clostridioides difficile is the leading cause of healthcare-associated infections in the USA, with an estimated 1 billion dollars in excess cost to the healthcare system annually. C. difficile infection (CDI) has high recurrence rate, up to 25% after first episode and up to 60% for succeeding episodes. Preliminary in vitro and in vivo studies indicate that alanyl-glutamine (AQ) may be beneficial in treating CDI by its effect on restoring intestinal integrity in the epithelial barrier, ameliorating inflammation and decreasing relapse. Methods and analysis: This study is a randomised, placebo-controlled, double-blind, phase II clinical trial. The trial is designed to determine optimal dose and safety of oral AQ at 4, 24 and 44 g doses administered daily for 10 days concurrent with standard treatment of non-severe or severe uncomplicated CDI in persons age 18 and older. The primary outcome of interest is CDI recurrence during 60 days post-treatment follow-up, with the secondary outcome of mortality during 60 days post-treatment follow-up. Exploratory analysis will be done to determine the impact of AQ supplementation on intestinal and systemic inflammation, as well as intestinal microbial and metabolic profiles. Ethics and dissemination: The study has received University of Virginia Institutional Review Board approval (HSR200046, Protocol v9, April 2023). Findings will be disseminated via conference presentations, lectures and peer-reviewed publications. Trial registration number NCT04305769.
Ehrlichia chaffeensis-associated Hemophagocytic Lymphohistiocytosis: A Case Series and Literature Review
Fazili, Tasaduz; Bansal, Ekta N.; Garner, Dorothy C.; Bajwa, Vijayendra; Kaur, Harpreet; Schleupner, Charles J. (American Journal of Medical Case Reports, 2021-08-17)
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon condition characterized by abnormal, excessive immune activation resulting in severe cytopenias from an uncontrolled inflammatory response. It can be primary/ familial or secondary/sporadic. Infections, particularly viral infections are a common cause of secondary HLH. HLH due to Human monocytic ehrlichiosis (HME) is very rare, hence we are reporting our cases. Objective: To review cases of Ehrlichia-associated HLH at our institution and perform a literature review regarding this entity. Methods: We reviewed cases of Ehrlichia-associated HLH for the previous two years at our institution (Carilion Clinic). We then performed a review of the published literature on it, using Pubmed. Results: Over the past two years, five cases of Ehrlichia-associated HLH were diagnosed at our hospital. The average age of the patients was 67 years with predominantly males. All the patients were pancytopenic, and a majority had abnormal liver function tests. Diagnosis of ehrlichiosis was made by serum polymerase chain reaction (PCR) assay on blood. Patients had further testing done because of lack of clinical improvement. All patients had significantly elevated ferritin levels. Bone marrow biopsy samples of all patients showed findings of hemophagocytosis. All, but one, patients were treated with doxycycline and a combination of etoposide and dexamethasone. Three patients recovered while two died. On review of medical literature, we found a total of only 36 cases of Ehrlichia-associated HLH, including our five cases. There were 19 adults and 17 children. Both population groups showed varying degrees of pancytopenia. Splenomegaly was relatively uncommon, seen in less than one-third of the patients. Ferritin and triglyceride levels were routinely elevated. Bone marrow biopsy showing hemophagocytosis was the confirmatory test in all patients. A significant number of patients, both adults and children, required a combination of doxycycline and chemotherapy (etoposide and dexamethasone) to achieve clinical cure. Children had a better prognosis than adults, with one child and four adults succumbing to their illness. Conclusions: Ehrlichia-associated HLH is a rare but emerging disease entity. In endemic areas, a high degree of suspicion is required to diagnose ehrlichiosis and HLH resulting from it. Early diagnosis and prompt initiation of treatment for HLH is key to a favorable outcome.
Mnemonic Discrimination Deficits in First-Episode Psychosis and a Ketamine Model Suggest Dentate Gyrus Pathology Linked to NMDA Receptor Hypofunction
Kraguljac, Nina Vanessa; Carle, Matthew; Frolich, Michael A.; Tran, Steve; Yassa, Michael A.; White, David Matthew; Reddy, Abhishek; Lahti, Adrienne Carol (Elsevier, 2021-12)
Background: Converging evidence from neuroimaging and postmortem studies suggests that hippocampal subfields are differentially affected in schizophrenia. Recent studies report dentate gyrus dysfunction in chronic schizophrenia, but the underlying mechanisms remain to be elucidated. Here, we sought to examine if this deficit is already present in first-episode psychosis and if NMDA receptor hypofunction, a putative central pathophysiological mechanism in schizophrenia, experimentally induced by ketamine, would result in a similar abnormality. Methods: We applied a mnemonic discrimination task selectively taxing pattern separation in two experiments: 1) a group of 23 patients with first-episode psychosis and 23 matched healthy volunteers and 2) a group of 19 healthy volunteers before and during a ketamine challenge (0.27 mg/kg over 10 min, then 0.25 mg/kg/hour for 50 min, 0.01 mL/s). We calculated response bias–corrected pattern separation and recognition scores. We also examined the relationships between task performance and symptom severity as well as ketamine levels. Results: We reported a deficit in pattern separation performance in patients with first-episode psychosis compared with healthy volunteers (p = .04) and in volunteers during the ketamine challenge compared with baseline (p = .003). Pattern recognition was lower in patients with first-episode psychosis than in control subjects (p < .01). Exploratory analyses revealed no correlation between task performance and Repeatable Battery for the Assessment of Neuropsychological Status total scores or positive symptoms in patients with first-episode psychosis or with ketamine serum levels. Conclusions: We observed a mnemonic discrimination deficit in both datasets. Our findings suggest a tentative mechanistic link between dentate gyrus dysfunction in first-episode psychosis and NMDA receptor hypofunction.
Homicidal ideation and psychiatric comorbidities in the inpatient adolescents aged 12-17
Sun, Ching-Fang; Mansuri, Zeeshan; Trivedi, Chintan; Vadukapuram, Ramu; Reddy, Abhishek (Frontiers, 2022-11-16)
Objectives: Adolescents with a homicidal tendency is a growing concern in the United States. Studies in the past have showcased the relationship between homicidal ideation (HI) and psychiatric illnesses, but very limited information is available on the adolescent and inpatient population. We aim to evaluate the prevalence of demographic characteristics and psychiatric disorders in adolescents with and without HI. Materials and methods: Adolescent (age 12–17) population admitted to the hospital with the diagnosis of homicidal ideation was identified from the 2016–2018 National Inpatient Sample Dataset (NISD). Patients without HI were defined as the control group. The prevalence of psychiatric comorbidities between the groups was compared by applying the Rao-Scott adjusted chi-square test. We used multivariable logistic regression to generate odds ratio (OR) of homicidal ideation as an outcome; we adjusted age, sex, race, socioeconomic status, substance use disorders, alcohol use disorders, and psychiatric comorbidities. Results: A total of 18,935 patients (mean age: 14.5) with HI diagnosis were identified in this study. Majority of the patients were male subjects in the HI group compared to the control group (58.7 vs. 41.2%, p < 0.001). Racially, HI was more prevalent in white race (56.0 vs. 52.6%, p < 0.001) and black race (22.3 vs. 17.8%, p < 0.001), compared to Hispanic race (14.9 vs. 21.3%, p < 0.001). Major depression (Odds ratio [OR]: 2.66, p < 0.001), bipolar disorder (OR: 3.52, p < 0.001), anxiety disorder (OR: 1.85, p < 0.001), ADHD, and other conduct disorders (OR: 4.01, p < 0.001), schizophrenia (OR: 4.35, p < 0.001) are strong predictors of HI. Suicidality was prevalent in 66.9% of patients with HI. Conclusion: We found a higher prevalence of psychiatric illnesses such as depression, anxiety, and bipolar disorder in adolescents with homicidal ideation in the inpatient setting. White and black races were more prevalent in patients with homicidal ideation. Further large-scale longitudinal research studies are warranted to establish the correlation between psychiatric disorders and homicidal ideation among adolescents.
High-risk subgroups were not identified to benefit from thromboprophylaxis after hospitalization for COVID-19
Baumann Kreuziger, Lisa; Kwon, Taeim; Kasthuri, Raj S.; Wahid, Lana; Miller, Peter J.; Enders, Kimberly; Wahed, Abdus S.; Anstrom, Kevin J.; Wang, Tracy Y.; Ortel, Thomas L. (Elsevier, 2024-05-01)
Background: The Accelerating COVID-19 Therapeutic Interventions and Vaccines-4c (ACTIV-4c) trial investigated prophylactic apixaban for 30 days following hospitalization for COVID-19. The overall incidence of early postdischarge death or thromboembolism was low, and the trial was closed early. Objectives: To identify a high-risk patient population who might benefit from postdischarge thromboprophylaxis through subgroup analyses stratified by age, race/ethnicity, obesity, D-dimer elevation, World Health Organization score, and modified International Medical Prevention Registry on Venous Thromboembolism score on 30-day composite outcome of all-cause death, arterial thromboembolism (ATE), and venous thromboembolism (VTE). Methods: Cumulative incidences of all-cause death, ATE, and VTE within 30 days were described for each subgroup. Time to death, ATE, or VTE by 30 days was analyzed using Cox proportional hazard models with interaction testing for each subgroup. Results: Among 1217 patients randomized to apixaban or placebo group, 32% were >60 years old. Modified International Medical Prevention Registry on Venous Thromboembolism score was ≥4 in 2% and 2 or 3 with an elevated D-dimer in an additional 9% of participants. The overall incidence of the primary endpoint was 2.13% in the apixaban group and 2.31% in the placebo group. At day 30, similar rates of the primary endpoint occurred within subgroups, except for participants aged >60 years. No benefit of thromboprophylaxis was seen in any subgroup. Conclusion: The combined incidence of 30-day death, ATE, and VTE was low in patients who survived COVID-19 hospitalization, except in patients over age 60 years. Due to the limited number of events, the findings remain inconclusive; nonetheless, the study did not identify a high-risk subgroup that would derive benefits from extended thromboprophylaxis.
Selective regulation of chemosensitivity in glioblastoma by phosphatidylinositol 3-kinase beta
Pridham, Kevin J.; Hutchings, Kasen R.; Beck, Patrick; Liu, Min; Xu, Eileen; Saechin, Erin; Bui, Vincent; Patel, Chinkal; Solis, Jamie; Huang, Leah; Tegge, Allison; Kelly, Deborah F.; Sheng, Zhi (Elsevier, 2024-06-21)
Resistance to chemotherapies such as temozolomide is a major hurdle to effectively treat therapy-resistant glioblastoma. This challenge arises from the activation of phosphatidylinositol 3-kinase (PI3K), which makes it an appealing therapeutic target. However, non-selectively blocking PI3K kinases PI3K⍺/β/𝛿/𝛾 has yielded undesired clinical outcomes. It is, therefore, imperative to investigate individual kinases in glioblastoma’s chemosensitivity. Here,wereport that PI3K kinases were unequally expressed in glioblastoma, with levels of PI3Kβ being the highest. Patients deficient of O6-methylguanine-DNA-methyltransferase(MGMT) and expressing elevated levels of PI3Kβ, defined as MGMT-deficient/PI3Kβ-high, were less responsive to temozolomide and experienced poor prognosis. Consistently, MGMT-deficient/PI3Kβ-high glioblastoma cells were resistant to temozolomide. Perturbation of PI3Kβ, but not other kinases, sensitized MGMTdeficient/ PI3Kβ-high glioblastoma cells or tumors to temozolomide. Moreover, PI3Kβ-selective inhibitors and temozolomide synergistically mitigated the growth of glioblastoma stem cells. Our results have demonstrated an essential role of PI3Kβ in chemoresistance, making PI3Kβ-selective blockade an effective chemosensitizer for glioblastoma.
Digital biomarkers: 3PM approach revolutionizing chronic disease management — EPMA 2024 position
Smokovski, Ivica; Steinle, Nanette; Behnke, Andrew J.; Bhaskar, Sonu M. M.; Grech, Godfrey; Richter, Kneginja; Niklewski, Gunter; Birkenbihl, Colin; Parini, Paolo; Andrews, Russell J.; Bauchner, Howard; Golubnitschaja, Olga (2024-05-11)
Non-communicable chronic diseases (NCDs) have become a major global health concern. They constitute the leading cause of disabilities, increased morbidity, mortality, and socio-economic disasters worldwide. Medical condition-specific digital biomarker (DB) panels have emerged as valuable tools to manage NCDs. DBs refer to the measurable and quantifiable physiological, behavioral, and environmental parameters collected for an individual through innovative digital health technologies, including wearables, smart devices, and medical sensors. By leveraging digital technologies, healthcare providers can gather real-time data and insights, enabling them to deliver more proactive and tailored interventions to individuals at risk and patients diagnosed with NCDs. Continuous monitoring of relevant health parameters through wearable devices or smartphone applications allows patients and clinicians to track the progression of NCDs in real time. With the introduction of digital biomarker monitoring (DBM), a new quality of primary and secondary healthcare is being offered with promising opportunities for health risk assessment and protection against health-to-disease transitions in vulnerable sub-populations. DBM enables healthcare providers to take the most cost-effective targeted preventive measures, to detect disease developments early, and to introduce personalized interventions. Consequently, they benefit the quality of life (QoL) of affected individuals, healthcare economy, and society at large. DBM is instrumental for the paradigm shift from reactive medical services to 3PM approach promoted by the European Association for Predictive, Preventive, and Personalized Medicine (EPMA) involving 3PM experts from 55 countries worldwide. This position manuscript consolidates multi-professional expertise in the area, demonstrating clinically relevant examples and providing the roadmap for implementing 3PM concepts facilitated through DBs.
Clinical Theranostics in Recurrent Gliomas: A Review
Hoggarth, Austin R.; Muthukumar, Sankar; Thomas, Steven M.; Crowley, James; Kiser, Jackson; Witcher, Mark R. (MDPI, 2024-04-28)
Gliomas represent the most commonly occurring tumors in the central nervous system and account for approximately 80% of all malignant primary brain tumors. With a high malignancy and recurrence risk, the prognosis of high-grade gliomas is poor, with a mean survival time of 12–18 months. While contrast-enhanced MRI serves as the standard diagnostic imaging modality for gliomas, it faces limitations in the evaluation of recurrent gliomas, failing to distinguish between treatment-related changes and tumor progression, and offers no direct therapeutic options. Recent advances in imaging modalities have attempted to address some of these limitations, including positron emission tomography (PET), which has demonstrated success in delineating tumor margins and guiding the treatment of recurrent gliomas. Additionally, with the advent of theranostics in nuclear medicine, PET tracers, when combined with therapeutic agents, have also evolved beyond a purely diagnostic modality, serving both diagnostic and therapeutic roles. This review will discuss the growing involvement of theranostics in diagnosing and treating recurrent gliomas and address the associated impact on quality of life and functional recovery.
Enhancing safety in the ischaemic and haemorrhagic stroke population: exploring the efficacy of self-releasing chair alarm belts
Weppner, Justin; Gee, Alaric; Mesina, Kevin (BMJ, 2024-02-21)
Introduction A quality improvement study evaluated the effectiveness of implementing self-releasing chair alarm belts in an inpatient rehabilitation facility (IRF) for patients who had a stroke. The objective of this study is to assess the effectiveness of self-releasing chair alarms as a chair-level fall preventive tool in patients who had a stroke in the IRF setting. Methods A preintervention and postintervention quality improvement study was conducted in an IRF to address the high rate of falls in the stroke population. Falls from wheelchairs were identified as a significant concern, leading to the implementation of self-releasing safety belts (Posey HeadStart Notification Sensor Belts) with alarm systems as an intervention. In the preintervention phase (July 2021 to January 2022) falls from chairs while on standard fall precautions were recorded to establish a baseline. In the intervention phase, the self-releasing chair alarm belts were introduced along with standard fall precautions. The postintervention phase spanned from February 2022 to July 2022. Results In the preintervention phase, 20 out of 86 stroke subjects experienced a total of 30 falls from chairs. However, in the postintervention phase, only one subject experienced a fall from a chair out of 104 stroke subjects. The mean percentage of subjects involved in falls decreased from 24±11.4% to 1±0.4% (p<0.00001), and the mean fall rate per 1000 patient days declined from 4.6±2 to 0.2±0.1 (p<0.0001). Conclusions The implementation of self-releasing chair alarm belts significantly reduced falls from chairs among patients who had a stroke in the IRF setting. These findings highlight the effectiveness of this intervention in improving patient safety and fall prevention in IRFs.
Antibiotic exposure is associated with decreased risk of psychiatric disorders
Kerman, Ilan A.; Glover, Matthew E.; Lin, Yezhe; West, Jennifer L.; Hanlon, Alexandra L.; Kablinger, Anita S.; Clinton, Sarah M. (Frontiers, 2024-01-08)
Objective: This study sought to investigate the relationship between antibiotic exposure and subsequent risk of psychiatric disorders. Methods: This retrospective cohort study used a national database of 69 million patients from 54 large healthcare organizations. We identified a cohort of 20,214 (42.5% male; 57.9 ± 15.1 years old [mean ± SD]) adults without prior neuropsychiatric diagnoses who received antibiotics during hospitalization. Matched controls included 41,555 (39.6% male; 57.3 ± 15.5 years old) hospitalized adults without antibiotic exposure. The two cohorts were balanced for potential confounders, including demographics and variables with potential to affect: the microbiome, mental health, medical comorbidity, and overall health status. Data were stratified by age and by sex, and outcome measures were assessed starting 6 months after hospital discharge. Results: Antibiotic exposure was consistently associated with a significant decrease in the risk of novel mood disorders and anxiety and stressor-related disorders in: men (mood (OR 0.84, 95% CI 0.77, 0.91), anxiety (OR 0.88, 95% CI 0.82, 0.95), women (mood (OR 0.94, 95% CI 0.89,1.00), anxiety (OR 0.93, 95% CI 0.88, 0.98), those who are 26–49 years old (mood (OR 0.87, 95% CI 0.80, 0.94), anxiety (OR 0.90, 95% CI 0.84, 0.97)), and in those ≥50 years old (mood (OR 0.91, 95% CI 0.86, 0.97), anxiety (OR 0.92, 95% CI 0.87, 0.97). Risk of intentional harm and suicidality was decreased in men (OR 0.73, 95% CI 0.55, 0.98) and in those ≥50 years old (OR 0.67, 95% CI 0.49, 0.92). Risk of psychotic disorders was also decreased in subjects ≥50 years old (OR 0.83, 95 CI: 0.69, 0.99). Conclusion: Use of antibiotics in the inpatient setting is associated with protective effects against multiple psychiatric outcomes in an age- and sex-dependent manner.
Rare Occurrence of Extradigital Glomangioma in the Prepatellar Bursa of a 40-Year-Old: A Case Study
Crawford, Dylan C.; O'Malley, Michael; Samuel, Linsen T. (Indian Orthopaedic Research Group, 2022-07)
INTRODUCTION: A solitary subcutaneous mass can be a common clinical finding for patients symptomatic for knee pain, especially when direct pressure by kneeling on the anterior aspect of the knee causes pain. CASE REPORT: We present a 40-year-old who noticed a small fluid filled mass that has become progressively larger and more painful over the past 7 years. The patient's primary complaint was sharp pain with direct contact. Ultimately, a surgical excision was performed to remove the mass. The histopathological report came back as a glomangioma, a subtype of a glomus tumor. To the best of our knowledge, this is the youngest reported case of a glomangioma of the knee. CONCLUSION: Glomus tumors found on the digital and subungual regions of patients are a common clinical finding. An extradigital occurrence of a glomangioma, a subtype of a glomus tumor, is rarely found, especially in younger patients. Therefore, a histopathological examination must be done after the removal of any subcutaneous mass.
Complicated Post-Partum HELLP Syndrome Causing Acute Renal Failure and a Spontaneous Acute Subdural Hematoma
Shah, Farhan; Patel, Niel; Patel, Brijesh B. (Springer, 2021-02-08)
HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and thrombocytopenia. It is a devastating illness that typically occurs in the third trimester of gestation. We present a unique case of complicated post-partum HELLP syndrome. The patient was a 34-year-old Caucasian G1PO woman at 40 weeks' gestational age who presented for induction of labor. She underwent successful vaginal delivery. However, postoperatively the patient developed HELLP syndrome complicated by acute renal failure. She was transferred to the intensive care unit, where her renal function continued to decline, ultimately necessitating hemodialysis. She subsequently spontaneously developed an acute subdural hematoma. Most cases of HELLP syndrome occur in the third trimester, whereas fewer manifest post-partum. The pathophysiology of HELLP syndrome is poorly understood. While the defining organ of injury in HELLP syndrome is the liver, both kidney injury and spontaneous subdural hematomas can occur, as seen in this patient. The gold standard therapy for HELLP syndrome is prompt delivery of the fetus. HELLP syndrome continues to be a serious constellation of symptoms that can affect women late in their gestational period. As illustrated in this case report, prompt diagnosis of HELLP syndrome and appropriate management is critical.
The Lung Point Sign, not Pathognomonic of a Pneumothorax
Aziz, Sameh G.; Patel, Brijesh B.; Ie, Susanti R.; Rubio, Edmundo R. (Ultrasound Quarterly, 2016-09-01)
Since the development of portable ultrasonography equipment, this technology has provided clinicians the ability to evaluate a variety of lung pathology at the bedside, but we are still learning how to accurately interpret the acquired images. Adequate interpretation and recognition of certain signs is crucial to diagnosing pathological processes. In addition, such signs must be adequately correlated with the patient's medical condition. For instance, the "lung point sign" has been traditionally considered to be pathognomonic for the presence of a pneumothorax, yet such finding may be present in patients with bullous lung disease without a pneumothorax. We present a case of an 83-year-old man with underlying chronic obstructive pulmonary disease. Bedside ultrasonography identified a "lung point sign" initially suggesting a possible pneumothorax. Further evaluation demonstrated absence of pneumothorax, with the patient having a large bulla. To our knowledge, this is the first case reported demonstrating that the "lung point sign" is not always indicative of a pneumothorax. We discuss the importance of both clinical correlation and understanding of the underlying pathophysiology when reviewing ultrasound images to accurately interpret ultrasound findings.
Introduction of a formative assessment tool in a post-graduate training program in India: a mixed methods evaluation
Douglass, Katherine; Ahluwalia, Tania; McKiernan, Brianna; Patel, Heena; Powell, Natasha; Keller, Jacob; Toy, Serkan (2024-03-01)
Background: Our institution has longstanding post-graduate education and training partnership programs in Emergency Medicine (EM) across India. A programmatic challenge has been the integration and uptake of evidence-based medicine and lifelong learning concepts. Formative assessment (FA) is intended to enable learners to monitor learning, identify strengths and weaknesses, and target areas of growth. As part of a program improvement initiative, we introduced an online FA tool to existing summative assessments. This study investigates how the FA tool was used and perceived by trainees. Methods: 246 trainees across 19 sites were given access to the FA tool. Usage metrics were monitored over 12 months. Semi-structured interviews were conducted in person with trainees using a purposive sampling methodology. A hybrid thematic analysis approach was used to determine themes. Interviews were coded independently by two blinded researchers using NVivo software. The study was deemed exempt by our institutional review board. Results: There was high variability in trainees’ utilization of the FA tool. Trainees who used the FA tool more performed better on summative exams (r = 0.35, p < 0.001). Qualitative analysis revealed that trainees were motivated to learn for improved clinical knowledge and to be a good physician, not only passing exams. Benefits of the tool included the relationship to clinical practice and thorough explanation of answers, while disadvantages included topics unrelated to India. Conclusion: The integration of a FA tool has provided positive outcomes for trainees in EM education programs in India. Lessons learned may apply globally to other contexts and programs.
Infectious Aortitis Due to Salmonella Species Masquerading as Lung Malignancy
O'Shea, John-Paul; Ahmad, Darakhshan; Garner, Dorothy; Fazili, Tasaduq N. (Elsevier, 2023-07-10)
Infectious aortitis is a rare but devastating vascular infection with mortality exceeding 40%. Early diagnosis is crucial but often hampered by radiographic mimickers. We report a patient who was thought to have lung cancer but ultimately found to have an infected aortic aneurysm and bacteremia owing to Salmonella species. Owing to surgical contraindications, he was treated palliatively with an initial regimen of intravenous ampicillin/sulbactam followed by lifelong oral antibiotic suppression. He ultimately rejected his diagnosis, discontinued medications, and was lost to follow-up. (Level of Difficulty: Intermediate.)
Acute onset apathy in the context of malignancy: a case report
Samarbafzadeh, Ehsan; Adikey, Archana; Alee Koloukani, Sahar (2021-05-03)
Characterization and LDL-C management in a cohort of high and very high cardiovascular risk patients: The PORTRAIT-DYS study
Gavina, Cristina; Seabra-Carvalho, Daniel; Aguiar, Carlos; Anastassopoulou, Anastassia; Teixeira, Carla; Ruivo, Jorge A.; Almeida, Élia; Luz-Duarte, Leonor; Corte-Real, Ana; Canelas-Pais, Mariana; Taveira-Gomes, Tiago (Wiley, 2023-11-06)
Aim: This study aims to characterize sociodemographic and clinical characteristics, use of lipid-lowering therapies (LLTs), and low-density lipoprotein cholesterol (LDL-C) control in a population with increased cardiovascular (CV) risk. Methods: A cross-sectional observational study that uses electronic health records of patients from one hospital and across 14 primary care health centers in the North of Portugal, spanning from 2000 to 2020 (index date). Patients presented at least (i) 1 year of clinical data before inclusion, (ii) one primary care appointment 3 years before the index date, and (iii) sufficient data for CV risk classification. Patients were divided into three cohorts: high CV risk; atherosclerotic cardiovascular disease (ASCVD) risk equivalents without established ASCVD; evidence of ASCVD. CV risk and LDL-C control were defined by the 2019 and 2016 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) dyslipidemia guidelines. Results: A total of 51 609 patients were included, with 23 457 patients classified as high CV risk, 19 864 with ASCVD equivalents, and 8288 with evidence of ASCVD. LDL-C control with 2016 ESC/EAS guidelines was 32%, 10%, and 18% for each group, respectively. Considering the ESC/EAS 2019 guidelines control level was even lower: 7%, 3%, and 7% for the same cohorts, respectively. Patients without any LLT prescribed ranged from 37% in the high CV risk group to 15% in patients with evidence of ASCVD. Conclusion: We found that LDL-C control was very low in patients at higher risk of CV events. An alarming gap between guidelines on dyslipidemia management and clinical implementation persists, even in those at very high risk or with established ASCVD.

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