To determine the thresholds of selective shunting in carotid endarterectomy during general anesthesia, we compared transcranial Doppler ultrasonography and cerebral oximetry (RSO2). During carotid cross-clamping, RSO2 and mean blood flow velocity in the middle cerebral artery (Vm,mca) was simultaneously monitored in 55 of 59 patients. A relative decrease in Vm,mca to <20% of preclamp velocity was the indication for selective shunting. Three patients were shunted, two because of criteria of Vm,mca and one in which Vm,mca measurements were impossible. No postoperative neurological deficits occurred. During cross-clamping, both Vm,mca (42+/-16 vs. 26+/-12 cm/s; P<0.001) and RSO2 (68+/-7% vs. 62+/-8%; P<0.01) decreased and a significant correlation between %Vm,mca and DeltaRSO2 was found (R(2) = 0.40; P = 0.003). Decreases in RSO2 >13% identified two patients later shunted; however, this threshold would have indicated unnecessary shunting in seven patients (false positives = 17%). Transcranial Doppler ultrasonography identified patients at risk for ischemia more accurately than RSO2. Relying on RSO2 alone would increase the number of unnecessary shunts because of the low specificity. Accepting higher decreases in RSO2 does not appear reasonable because it bears the risk of a low sensitivity.

Problem:Medical school curriculum continues to search for methods to develop a conceptual educational framework that promotes the storage, retrieval, transfer, and application of basic science to the human experience. To achieve this goal, we propose a metacognitive approach that integrates basic science with the humanistic and health system aspects of medical education.Intervention:During the week, via problem-based learning and lectures, first-year medical students were taught the basic science underlying a disease. Each Friday, a patient with the disease spoke to the class. Students then wrote illness scripts, which required them to metacognitively reflect not only on disease pathophysiology, complications, and treatments but also on the humanistic and health system issues revealed during the patient encounter. Evaluation of the intervention was conducted by measuring results on course exams and national board exams and analyzing free responses on the illness scripts and student course feedback. The course exams and National Board of Medical Examiners questions were divided into 3 categories: content covered in lecture, problem-based learning, or patient + illness script. Comparisons were made using Student t-test. Free responses were inductively analyzed using grounded theory methodology.Context:This curricular intervention was implemented during the first 13-week basic science course of medical school. The main objective of the course, Scientific Principles of Medicine, is to lay the scientific foundation for subsequent organ system courses. A total of 150 students were enrolled each year. We evaluated this intervention over 2 years, totaling 300 students.Outcome:Students scored significantly higher on illness script content compared to lecture content on the course exams (mean difference = 11.1, P = .006) and national board exams given in December (mean difference = 21.8, P = .0002) and June (mean difference = 12.7, P = .016). Themes extracted from students’ free responses included the following: relevance of basic science, humanistic themes of empathy, resilience, and the doctor-patient relationship, and systems themes of cost, barriers to care, and support systems.Lessons learned:A metacognitive approach to learning through the use of patient encounters and illness script reflections creates stronger conceptual frameworks for students to integrate, store, retain, and retrieve knowledge.

Point your SmartPhone at the code above. If you have a QR code reader, the video abstract will appear. Or use: https://youtu.be/gsADFoLUAvc Background: Experiential vertical integration of basic science with clinical concepts remains a challenge in medical school curricula. In addition, training physicians in nutritional competency that translates into patient care is a challenging endeavor ranging from biochemical mechanisms to socioeconomic challenges. Methods: Employing a social constructivism paradigm, we implemented a collaborative cook-off competition in a basic science course where 140 first-year medical students per year translated their studies of inborn errors of metabolism, energy metabolism, micronutrients and immunology into edible creations intended for people with disorders requiring dietary management. After learning about the disorders in lecture, problem-based learning, teambased learning and through patient interviews, four problem-based learning groups (7 students per group) were assigned to prepare food dishes for one of the five assigned disorders. Together, students researched the dietary requirements, shopped, paid for, prepared, presented and shared their food. To the class, faculty and re-invited patients, the groups explained the dietary restrictions, the chosen ingredients, how they prepared the food, and why their dish was suitable for the disorder. Each category was judged and awarded a first-place food prize with a grand prize at the end. At the completion of the course, student feedback was elicited via anonymous evaluations. Over 3 years, 380 comments were collected. We used grounded theory to generate a codebook that was then analyzed by the authors for overarching themes. Results: Qualitative results described three major themes: increased relevance of basic science to real life, increased empathy towards complying with dietary restrictions, and increased student group cohesiveness. Conclusion: The patient-centered cook-off competition taught students the relevance of basic science but in addition, it taught empathy towards the patient experience. We also discovered that the process of food preparation was a bonding experience that promoted collaboration, cohesiveness and friendship within the student class.

The Obesity Paradox describes the counterintuitive finding that although obesity contributes to the development of chronic conditions such as chronic kidney disease and cardiovascular disease, obesity seems to improve mortality in patients with these diseases. This paradox has also been sited in the critical care literature in regard to acute kidney injury, obesity and mortality. This study's objective is to examine the impact of obesity and post-surgical acute kidney injury on hospital length of stay and 2-year mortality after orthopedic surgery.We reviewed the electronic medical records of all adult elective orthopedic surgery patients over 2 years in a large academic hospital. The 1783 patients who met inclusion criteria were divided into obese (body mass index, BMI ≥ 30, n = 1123) and non-obese groups (BMI <30, n = 660). Demographics, medications, comorbidities, and perioperative variables were included in multivariable logistic regression analyses with acute kidney injury, length of hospital stay, and two-year mortality as primary outcomes. Outcomes were analyzed for the entire group, the obese cohort and the non-obese cohort.Acute kidney injury developed in 5% of the post-surgical orthopedic patients. Obesity increased the likelihood of developing acute kidney injury post orthopedic surgery (odds ratio [OR] = 1.82; 95% Confidence interval [CI] 1.05–3.15, P = .034). Acute kidney injury increased length of stay by 1.3 days and increased the odds of two-year mortality (OR = 2.08; 95% CI 1.03–4.22, P = .041). However, obese patients had a decreased likelihood of two-year mortality (OR = 0.53; 95% CI 0.33–0.84, P = .009).In adult orthopedic surgery patients, obesity increased the risk of acute kidney injury. Patients who developed an acute kidney injury had longer hospital stays and higher two-year mortality. Paradoxically, obesity decreased two-year mortality.

Introduction/aims: Muscle specific kinase (MuSK) antibody positive myasthenia gravis (MuSK+MG) is a form of MG with bulbar-predominant symptoms often resistant to conventional treatments. MuSK+MG patients may have an electrodiagnostic (EDX) profile distinct from other MG. This study compares EDX features of MuSK+MG to acetylcholine receptor (AChR) antibody positive MG (AChR+MG) to discern whether any unique EDX patterns exists that can aid in clinical diagnosis.Methods:From January 1 2010 through December 31 2020, all MuSK+MG patients at our institution were identified and randomly matched to an AChR+MG cohort in a 1:2 ratio based on sex, age of onset, and subsequently MGFA clinical severity for a case-control study. Each patient’s clinical profile, treatment, and EDX testing were summarized and analyzed.Results:Twenty-two MuSK+MG patients (18 female) and 44 AChR+MG patients were studied. The average symptom duration at presentation was shorter in the MuSK+MG group (4.7 years) compared to AChR +MG (10.9 years). Myotonic discharges were rare in both groups but more frequently observed in MuSK+MG patients (10%) identified in 5 muscles in 2 patients compared to AChR+MG (2%) noted in only 1 muscle in 1 patient. MuSK+MG patients more often had myopathic appearing motor unit potentials (MUPs) (41% versus 30%) compared to AChR+MG. Myopathic appearing MUPs were found in milder cases of MuSK+MG (MGFA class I-IIB) compared to AChR+MG (MGFA class IIB-V).Conclusions:MuSK+MG patients may have a recognizable EDX profile from AchR+MG that includes: 1) myotonic discharges, 2) greater occurrence of myopathic appearing MUPs in clinically mild disease, and 3) symptoms leading to earlier testing.

This study demonstrates that the transition period from peripheral vasoconstriction to vasodilation provides an opportunity for postoperative extubation.

How medical inter-professional (IP) education should be introduced to students is still a matter of research. We evaluated IP student attitudes before and after a busy “hands-on” clinical experience. During 3 separate trips, first/second year medical and physician assistant students and third/fourth year nursing students traveled to Central America to work together for 1 week in an underserved clinical setting. Student opinions on inter-professional education were obtained before and after Brigade-1 using the Readiness for Inter-professional Learning Scale validated questionnaire. From these results, a modified version of the survey was developed that included quantitative and qualitative responses. For brigades-2 and -3, students received this modified version of the survey pre and post brigade. Quantitative data was analyzed via paired student t test, and qualitative data was analyzed to identify emerging themes using constant comparative methodology by three separate investigators. No significant quantitative differences between IP student groups were observed in their evaluation of the importance of inter-professional education either before or after the brigades. Qualitative data noted pre-brigade expectations of positive IP, experiential and patient-centered cultural learning. Pre- and post-brigade student perspectives maintained a strong belief that high functioning IP care benefited the patient. Post-brigade perspectives revealed a shift in attitude from purely positive expectations to more practical aspects of teamwork, respect, and interpersonal relationships. Students believe that patient care benefits from IP collaboration. After a busy clinical experience requiring collaboration, students realized that functional teams require appropriate skills, roles, and respectful interpersonal relationships.

Objectives Symptomatic myopathy in sarcoidosis patients is not always due to sarcoid myopathy (SM). We investigated the clinical and pathological spectrum including myxovirus resistance protein A (MxA) expression among sarcoidosis patients. Methods We reviewed the Mayo Clinic database (May 1980 - December 2020) to identify sarcoidosis patients with myopathic symptoms and pathological evidence of myopathy. Results Among 5,885 sarcoidosis patients, 21 had symptomatic myopathy. Eight carried a diagnosis of sarcoidosis 5.5 years (median) prior to myopathy onset. Eleven patients had SM. The remaining had non-sarcoid myopathies (5 IBM, 1 immune-mediated necrotizing myopathy, 1 nonspecific myositis, 2 nonspecific myopathy and 1 steroid myopathy). Estimated frequency of IBM is 85 per 100 000 sarcoidosis patients. The following features were associated with non-sarcoid myopathies (p&lt; 0.05): 1) predominant finger flexor and quadriceps weakness, 2) modified Rankin scale (mRS) &gt;2 at time of diagnosis, 3) creatine kinase &gt; 500 U/l, and 4) absence of intramuscular granulomas. Sarcoplasmic MxA expression was observed in scattered myofibers in 3 patients, 2 of whom tested for dermatomyositis-specific autoantibodies and were negative. Immunosuppressive therapy led to improvement in mRS ≥ 1 in 5/10 SM, none of the 5 IBM, and 3/3 remaining patients with non-sarcoid myopathies. Discussion Symptomatic myopathy occurred in 0.36% of sarcoidosis. IBM was the second most common cause of myopathies after SM. Frequency of IBM in sarcoidosis is higher than general population. Recognition of features suggestive of alternative etiologies can guide proper treatment. Our findings of abnormal MxA expression warrants a larger study.