Introduction In 2018, the American College of Physicians formally acknowledged the importance of Point of Care Ultrasound (POCUS) to the practice of internal medicine (IM). For the military internist, POCUS training is critical for care of the trauma patient in austere environments, mass casualty events and natural disasters. While emergency medicine and critical care training programs have adopted POCUS education, few IM programs have integrated POCUS into their core curricula. We designed and implemented an iterative POCUS curriculum for trainees at a large military IM residency program over a two-year period. Methods In collaboration with our critical care and simulation departments, we developed a pilot curriculum consisting of five, 60-minute courses offered on a voluntary basis at monthly intervals throughout 2017. Based on the pilot’s success we incorporated a POCUS curriculum into the core academics received by all IM trainees during the 2017–2018 academic year. Trainees attended seven, 3-hour sessions during their scheduled academic time taught by subspecialists with POCUS expertise in an on-site simulation center. Baseline surveys and knowledge assessment examinations were administered during orientation and repeated at the end of the academic year. Comparison of results before and after the POCUS curriculum was the primary outcome evaluated. Results Intervention #1: Pilot, 2016–2017 Academic Year 45 trainees attended at least one course with an average of 1.8 sessions per trainee. Baseline survey data showed 91% of trainees believe POCUS is quite or extremely beneficial for their patients, but 73% feel slightly or not at all confident in POCUS knowledge. The pre-test mean and median scores were 71% and 77% respectively, which both increased to a post-test mean and median of 81%. Post-test mean percentage correct for trainees attending 1, 2, or 3 courses was 74%, 82%, and 91% respectively. Intervention #2: Incorporation of POCUS into Core Academics, 2017–2018 Academic Year All 75 trainees participated in training with an average of 3.77 sessions attended per trainee. Survey analysis revealed significant improvement in confidence of performing ultrasound-guided procedures (p = 0.0139), and a 37% absolute increase in respondents who anticipate using ultrasound in their clinical practice (p = 0.0003). The mean pre-test score was 67.8% with median of 63.6% while mean and median post-test scores were 82.1% and 81.8%, with an absolute improvement of 14.3% and 18.2% respectively (p = 0.0004). Conclusion A structured POCUS curriculum was successfully incorporated at a large multiservice military IM residency program, with demonstrated retention of knowledge, improved confidence in performance of ultrasound guided invasive procedures, and increased interest in the use of POCUS in future clinical practice. Similar programs should be implemented across all IM programs in military graduate medical education to enhance operational readiness and battlefield care.
Wilson's disease (WD) is a rare liver disease characterized by copper accumulation. Interestingly, iron overload has been observed in patients with WD without a diagnosis of primary hemochromatosis. This association has been recognized in the literature for almost two decades. 1-3 Of the chronic liver diseases known to cause secondary hemochromatosis, WD is classically not listed among them. The prevalence of secondary hemochromatosis in patients with WD is unknown. Despite the rarity of this disease, this knowledge is important because it yields therapeutic and monitoring implications in patients with WD. This article will begin with a review of the etiology and pathophysiology of WD, as well as the iron overload syndromes, followed by an explanation of the mechanism of secondary hemochromatosis in patients with WD. Finally, the authors will discuss the clinical implications of this knowledge with a focus on therapeutics. HePaTiC MeTal sTOraGe DisOrDers: COPPer anD irOn The mechanisms of hepatic transport of copper and iron are intimately related. 1 This relatedness can be observed in pathological states. 1 WD is a disorder of copper metabolism that is caused by mutations in the ATP7B gene, which codes for a copper transport protein in the liver. 4-6 The absent or compromised ATP7B protein not only causes copper accumulation in the liver and other organs but also reduces the amount of circulating ceruloplasmin. 4-6 Normally, the ATP7B protein loads copper onto ceruloplasmin, the primary means of copper transport throughout the body (Fig. 1). 1,7 In WD, the inability of the ATP7B protein to transport copper and thus facilitate its secretion through the biliary system leads to copper accumulation in the liver. 8,9 Copper accumulation and toxicity lead to hepatic, neurological, and psychiatric dysfunction, and
Factor XI (FXI) deficiency is an autosomal disorder which manifests as bleeding of varying severity. While homozygotes typically experience more dramatic bleeding symptoms, heterozygotes may experience clinically significant bleeding following surgical procedures or trauma, and therefore the condition is not purely recessive. The clinical significance of FXI deficiency is complicated in that FXI levels do not correlate well with bleeding severity, and in fact the bleeding risk is variable even for an individual in response to different haemostatic challenges. We present the case of a 74-year-old man of Ashkenazi Jewish heritage with a family and personal history of bleeding during surgical procedures, who presented with excessive bleeding following total thyroidectomy. He was found to have a FXI level of 52% (low normal). Genetic testing revealed that he was heterozygous for the c.403G>T mutation. This case demonstrates successful work-up and perioperative management of a patient with FXI deficiency.
Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes (POEMS) syndrome is a rare systemic disease, often unrecognised in the primary care setting. POEMS syndrome is associated with plasma cell dyscrasias and upregulation of vascular endothelial growth factor leading to systemic oedema, papilloedema and pulmonary hypertension. A wide constellation of presenting symptoms often leads to late diagnosis. Unrecognised and untreated disease rapidly leads to death from neuropathic exhaustion or cardiopulmonary failure. Treatment is extrapolated from other plasma cell dyscrasias such as multiple myeloma. Autologous peripheral blood stem cell transplantation (PBSCT) is often an important component of treatment. There is no established standard of care for POEMS syndrome. Therapies include lenalidomide, bortezomib and targeted monoclonal antibodies. We present a patient with POEMS syndrome who achieved rapid complete response to triple therapy consisting of lenalidomide, cyclophosphamide and prednisone, followed by high-dose chemotherapy and PBSCT.
Despite an unmet need for hepatologists in the United States, every year transplant hepatology (TH) fellowship positions remain unfilled. To address this, we investigated factors that influence trainee decisions about pursuing a career in hepatology. We invited current gastroenterology (GI) and TH fellows from all Accreditation Council for Graduate Medical Education‐accredited programs for the academic year 2014‐2015 to participate in an online survey about factors influencing decisions to train in hepatology. The same paper‐based survey was distributed at a nationally recognized GI board review course. The survey was completed by 180 participants of which 91% were current GI or TH fellows and 24% were not aware of the pilot 3‐year combined GI and TH training program. A majority of respondents (57%) reported that a shorter time (3 versus 4 years) to become board certification eligible would influence their decisions to pursue TH. The most common reasons for not pursuing hepatology were less endoscopy time (67%), additional length of training (64%), and lack of financial compensation (44%). Personal satisfaction (66%), management of complex multisystem disease (60%), and long‐term relationships with patients (57%) were the most attractive factors. Sixty‐one percent of participants reported having a mentor, and 94% of those with mentors reported that their mentors influenced their career decisions. Conclusion: We have identified several factors that affect fellows' decision to pursue TH. Shorter training, increased financial compensation, and increased endoscopy time are potentially modifiable factors that may increase the number of trainees seeking careers in hepatology and help alleviate the deficit of hepatologists. (Hepatology Communications 2017;1:347–353)
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