Case Report: Phenazopyridine-Induced Sulfhemoglobinemia in an 83-Year-Old Presenting with Dyspnea.

BACKGROUND: Sulfhemoglobinemia is a rare dyshemoglobinemia that presents similarly to methemoglobinemia. CASE REPORT: An 83-year-old woman with stage IV ovarian cancer presented to the Emergency Department after a near syncopal spell and was found to be cyanotic with a pulse oximetry reading of 71%. Pulse oximetry improved to only the mid-80s range with administration of high-flow oxygen. Her arterial blood gas on supplemental high-flow oxygen demonstrated a PaO2 of 413 mm Hg and methemoglobin of 1.2%, but also noted the interference of the co-oximetry with sulfhemoglobinemia. Further history revealed that the patient had recently been started on phenazopyridine. The phenazopyridine was stopped, an exchange transfusion was offered but declined, and the patient was discharged to home hospice. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The diagnosis of sulfhemoglobinemia can be challenging given that routine co-oximetry does not identify it. The clue to the diagnosis is that the cyanotic-appearing patient has a normal or elevated PaO2 and seems to be less ill than expected, given the degree of cyanosis. Sulfhemoglobinemia does not reverse with the administration of methylene blue.

A call for collaboration and consensus on training for endotracheal intubation in the medical intensive care unit.

Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.

Variability in Cytogenetic Testing for Multiple Myeloma: A Comprehensive Analysis From Across the United States.

PURPOSE: Multiple myeloma (MM) treatment has changed tremendously, with significant improvement in patient out-comes. One group with a suboptimal benefit is patients with high-risk cytogenetics, as tested by conventional karyotyping or fluorescence in situ hybridization (FISH). Methodology for these tests has been published, but not necessarily standardized. METHODS: We address variability in the testing and reporting methodology for MM cytogenetics in the United States using the ongoing African American Multiple Myeloma Study (AAMMS). We evaluated clinical and cytogenetic data from 1,221 patients (1,161 with conventional karyotyping and 976 with FISH) tested between 1998 and 2016 across 58 laboratories nationwide. RESULTS: Interlab and intralab variability was noted for the number of cells analyzed for karyotyping, with a significantly higher number of cells analyzed in patients in whom cytogenetics were normal (P 5.0025). For FISH testing, CD138-positive cell enrichment was used in 29.7% of patients and no enrichment in 50% of patients, whereas the remainder had unknown status. A significantly smaller number of cells was analyzed for patients in which CD138 cell enrichment was used compared with those without such enrichment (median, 50 v 200; P, .0001). A median of 7 loci probes (range, 1-16) were used for FISH testing across all laboratories, with variability in the loci probed even within a given laboratory. Chromosome 13-related abnormalities were the most frequently tested abnormality (n5956; 97.9%), and t(14;16) was the least frequently tested abnormality (n 5 119; 12.2%). CONCLUSIONS: We report significant variability in cytogenetic testing across the United States for MM, potentially leading to variability in risk stratification, with possible clinical implications and personalized treatment approaches.

Variation in Intensive Care Unit Intubation Practices in Pulmonary Critical Care Medicine Fellowship.

BACKGROUND: Endotracheal intubation in the intensive care unit (ICU) is a high-risk procedure. Competence in endotracheal intubation is a requirement for Pulmonary and Critical Care Medicine (PCCM) training programs, but fellow experience as the primary operator in intubating ICU patients has not been described on a large scale. OBJECTIVE: We hypothesized that significant variation surrounding endotracheal intubation practices in medical ICUs exists in United States (US) PCCM training programs. METHODS: We administered a survey to a convenience sample of US PCCM fellows to elicit typical intubation practices in the medical ICU. RESULTS: 89 discrete US PCCM and Internal Medicine CCM training programs (77% response rate) were represented. At 43% of programs, the PCCM fellow was "always or almost always" designated the primary operator for intubation of a medical ICU patient, whereas at 21% of programs, the PCCM fellow was "rarely or never" the primary operator responsible for intubating in the ICU. Factors influencing this variation included time of day, hospital policies, attending skill or preference, ICU census and acuity, and patient factors. There was an association between location of the training program, but not program size, and whether the PCCM fellow was the primary operator. CONCLUSION: There is significant variation in whether PCCM fellows are the primary operators to intubate medical ICU patients during training. Further work should explore how this variation affects fellow career development and competence in intubation.

A National Survey of Veterans Affairs Medical Centers' Cardiology Services.

A survey found that of cardiology services were widely available at facilities across the US Department of Veterans Affairs, but the types of services varied considerably based on facility complexity.

The financial value of vascular surgeons as operative consultants to other surgical specialties.

OBJECTIVE: Vascular surgeons provide assistance to other surgical specialties through planned and unplanned joint operative cases. The financial impact to the hospital of vascular surgeons as consultants in this context has yet to be quantified. We sought to quantify the financial value of services provided by consulting vascular surgeons in the performance of joint operative procedures, both planned and unplanned. METHODS: Hospital financial data were reviewed for all inpatient operative cases during a 3-year period (2013-2015). Cases in which a vascular surgeon provided operative assistance as a consultant to a nonvascular surgeon were identified and designated planned or unplanned. Contribution margin, defined as hospital revenue minus variable cost, was determined for each case. In addition, the contribution margin ratio (contribution margin divided by revenue) was determined for each cohort. Financial data for consulting cases was compared with all nonconsult cases. Data analysis was performed with nonparametric statistics. RESULTS: There were 208 cases with a primary nonvascular surgeon that required a vascular co-surgeon during the study period, 169 planned and 39 unplanned. For comparison, 19,594 nonconsult cases of other surgical specialties were identified. The median contribution margin was higher for vascular surgery consult cases compared with nonconsult cases ($14,406 [interquartile range, $63,192] vs $5491 [interquartile range $28,590]; P = .002). The overall contribution margin ratio was higher for vascular surgery consult cases (0.41) compared with control nonconsult cases (0.35). There was no difference in contribution margin and contribution margin ratio between planned and unplanned vascular surgery consult cases. CONCLUSIONS: Vascular surgeons provide essential operative assistance to other surgical specialties. This operative assistance is frequent and provides significant financial value, with high contribution margin and contribution margin ratio. Vascular surgeons, as consulting surgeons, enable the completion of highly complex cases and in this capacity provide significant financial value to the hospital.

Protocol for the Imagine HEALTH Study: Guided imagery lifestyle intervention to improve obesity-related behaviors and salivary cortisol patterns in predominantly Latino adolescents.

Innovative lifestyle interventions are needed to reduce type 2 diabetes risk in adolescents. This report describes the protocol of the Imagine HEALTH cluster randomized control trial, that tests an intervention based in Self-Determination Theory (SDT) and uses lifestyle education combined with the mind-body, complementary health modality of guided imagery (GI), to address obesity prevention and treatment in predominantly Latino adolescents. The primary aim is to determine the unique effects of each of the three major components of the 12-week lifestyle intervention (lifestyle education, stress reduction guided imagery, and lifestyle behavior guided imagery) compared to control on primary outcomes of physical activity (accelerometry), dietary intake (3-day recall), and stress biomarker levels (salivary cortisol). Secondary aims assess changes compared to controls in psychosocial outcomes (stress, well-being, depression), diabetes-related metabolic outcomes (adiposity, insulin resistance), maintenance of outcome changes for one year post-intervention, and SDT-based mediation of intervention effects. The development and rationale for each of the intervention components, study design, and outcome measurement processes are described. Adolescent participants recruited from four urban schools are cluster randomized by school into one of four arms of the 12-week (3-month) intervention, followed by 6 months of maintenance and 6 months of no contact. Outcome measures are assessed at the end of each period (3-, 9-, and 15-months). Results to date show successful recruitment of 97% of the target study population. Future results will demonstrate the effects of this integrative intervention on primary and secondary outcome measures in adolescents at risk for lifestyle-related metabolic disease.

Intrauterine Device Use and Cervical Cancer Risk: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the association between use of an intrauterine device (IUD) and risk of cervical cancer by subjecting existing data to critical review, quantitative synthesis, and interpretation. DATA SOURCES: We searched PubMed, Web of Science, ClinicalTrials.gov, and catalogs of scientific meetings and abstracts, theses, and dissertations queried from inception through July 2016. METHODS OF STUDY SELECTION: Examination of abstracts from 225 reports identified 34 studies with individual-level measures of use of an IUD and incident cervical cancer. By critically assessing the full text of these reports, independent reviewers identified 17 studies conducted without recognized sources of systematic error, of which 16 could be harmonized for meta-analysis. TABULATION, INTEGRATION, AND RESULTS: Point and interval estimates of the association between use of an IUD and incident cervical cancer were extracted from original reports into a structured database along with key features of study design and implementation. A random-effects meta-analysis was implemented to quantitatively synthesize extracted estimates and assess likely influence of publication bias, residual confounding, heterogeneity of true effect size, and human papillomavirus prevalence and cervical cancer incidence in source populations. Women who used an IUD experienced less cervical cancer (summary odds ratio 0.64, 95% CI 0.53-0.77). Neither confounding by recognized risk factors nor publication bias seems a plausible explanation for the apparent protective effect, which may be stronger in populations with higher cervical cancer incidence. CONCLUSION: Invasive cervical cancer may be approximately one third less frequent in women who have used an IUD. This possible noncontraceptive benefit could be most beneficial in populations with severely limited access to screening and concomitantly high cervical cancer incidence.

Experimental estimation of the spatial statistics of turbulence-induced index of refraction fluctuations in the upper atmosphere.

We present results from an experiment to estimate the parameters of homogeneous, isotropic optical turbulence in the upper atmosphere. The balloon-borne experiment made high-resolution temperature measurements at seven points on a hexagonal grid for altitudes from 12,000 to 18,000 m. From the temperature data, we obtained index of refraction fluctuations that can be used to compute a sample-based estimate for a parameterized description of the spatial autocorrelation of the turbulence. The three parameters of interest were a proportionality constant Pc, the power-law parameter alpha, and the outer scale L0. The results obtained for Pc are within the expected range and agree well with independent measurements made from a standard rising thermosonde measurement made approximately simultaneously with the data collection. Values for a were in the range 1.52 < or = alpha < or = 1.73 were observed, which are significantly less than the power law used in the Kolmogorov and von Karman models, alpha = 1.833. Values observed for L0 were in the range 5 < or = L0 < or = 19 m. Evidence that alpha may be consistently less than that used in the Kolmogorov and von Karman models likely has the most significant implications for systems that must work in or through the tropopause.

Measurement and data processing approach for detecting anisotropic spatial statistics of the turbulence-induced index of refraction fluctuations in the upper atmosphere.

We discuss a method of data reduction and analysis that has been developed for a novel experiment to detect anisotropic turbulence in the tropopause and to measure the spatial statistics of these flows. The experimental concept is to make measurements of temperature at 15 points on a hexagonal grid for altitudes from 12,000 to 18,000 m while suspended from a balloon performing a controlled descent. From the temperature data, we estimate the index of refraction and study the spatial statistics of the turbulence-induced index of refraction fluctuations. We present and evaluate the performance of a processing approach to estimate the parameters of an anisotropic model for the spatial power spectrum of the turbulence-induced index of refraction fluctuations. A Gaussian correlation model and a least-squares optimization routine are used to estimate the parameters of the model from the measurements. In addition, we implemented a quick-look algorithm to have a computationally nonintensive way of viewing the autocorrelation function of the index fluctuations. The autocorrelation of the index of refraction fluctuations is binned and interpolated onto a uniform grid from the sparse points that exist in our experiment. This allows the autocorrelation to be viewed with a three-dimensional plot to determine whether anisotropy exists in a specific data slab. Simulation results presented here show that, in the presence of the anticipated levels of measurement noise, the least-squares estimation technique allows turbulence parameters to be estimated with low rms error.