Long-term outcomes of patients with toxic shock syndrome: A matched cohort study.

OBJECTIVES: We examined long-term outcomes of toxic shock syndrome. METHODS: We conducted a matched cohort study of 630 patients with toxic shock syndrome and 5009 healthy controls between 2006 and 2021 in Quebec, Canada. Outcomes included hospitalization for renal, cardiovascular, hepatic, and other morbidity during 15 years of follow-up. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the risk of these outcomes over time, comparing patients with toxic shock syndrome relative to matched controls. RESULTS: Compared with healthy controls, rehospitalization rates at 15 years were higher for men with toxic shock syndrome (52.0 vs 30.0 per 100) but not for women (38.7 vs 45.6 per 100). In men, toxic shock syndrome was associated with an elevated risk of renal (HR 17.43, 95% CI 6.35-47.82), cardiovascular (HR 2.57; 95% CI 1.52-4.34), and hepatic hospitalization (HR 19.83, 95% CI 4.72-83.34). In women, toxic shock syndrome was associated with renal hospitalization (HR 4.71, 95% CI 1.94-11.45). Streptococcal toxic shock was associated with a greater risk of rehospitalization than staphylococcal toxic shock. CONCLUSIONS: Toxic shock syndrome is associated with rehospitalization up to 15 years later, especially in men. These patients may benefit from continued follow-up to prevent long-term morbidity.

Stir Fry with a Side of Extracorporeal Membrane Oxygen: Management of Cardiogenic Shock Secondary to Unintentional Aconitine Ingestion.

Plant exposures leading to systemic or topical toxicity are common presentations seen in the emergency department. While often nonfatal, certain highly toxic plants result in cardiovascular or respiratory failure requiring invasive management. We describe a 65-y-old patient who presented with a refractory ventricular dysrhythmia secondary to an unintentional ingestion of an aconitine-containing plant after incorrect identification. Despite aggressive treatment with vasopressors, intravenous fluids, antiarrhythmics, as well as electrolyte correction and multiple attempted synchronized cardioversions, the patient remained in a refractory dysrhythmia with cardiogenic shock. Venoarterial extracorporeal membrane oxygen (ECMO) therapy was initiated successfully and resulted in rapid resolution of the unstable dysrhythmia. The patient was weaned from ECMO in under 48 h and was discharged without neurological or cardiovascular sequelae. This case highlights management options available to clinicians who encounter toxicity associated with aconitine ingestion. Fatal consequences were averted, and caution is required with the use of plant-identifying applications and resources.

Deliberate practice of diagnostic clinical reasoning reveals low performance and improvement of diagnostic justification in pre-clerkship students.

PURPOSE: Diagnostic errors are a large burden on patient safety and improving clinical reasoning (CR) education could contribute to reducing these errors. To this end, calls have been made to implement CR training as early as the first year of medical school. However, much is still unknown about pre-clerkship students' reasoning processes. The current study aimed to observe how pre-clerkship students use clinical information during the diagnostic process. METHODS: In a prospective observational study, pre-clerkship medical students completed 10-11 self-directed online simulated CR diagnostic cases. CR skills assessed included: creation of the differential diagnosis (Ddx), diagnostic justification (DxJ), ordering investigations, and identifying the most probable diagnosis. Student performances were compared to expert-created scorecards and students received detailed individualized formative feedback for every case. RESULTS: 121 of 133 (91%) first- and second-year medical students consented to the research project. Students scored much lower for DxJ compared to scores obtained for creation of the Ddx, ordering tests, and identifying the correct diagnosis, (30-48% lower, p < 0.001). Specifically, students underutilized physical exam data (p < 0.001) and underutilized data that decreased the probability of incorrect diagnoses (p < 0.001). We observed that DxJ scores increased 40% after 10-11 practice cases (p < 0.001). CONCLUSIONS: We implemented deliberate practice with formative feedback for CR starting in the first year of medical school. Students underperformed in DxJ, particularly with analyzing the physical exam data and pertinent negative data. We observed significant improvement in DxJ performance with increased practice.

Development and Pilot Testing of a Data-Rich Clinical Reasoning Training and Assessment Tool.

PROBLEM: Clinical reasoning is a core competency for physicians and also a common source of errors, driving high rates of misdiagnoses and patient harm. Efforts to provide training in and assessment of clinical reasoning skills have proven challenging because they are either labor- and resource-prohibitive or lack important data relevant to clinical reasoning. The authors report on the creation and use of online simulation cases to train and assess clinical reasoning skills among medical students. APPROACH: Using an online library of simulation cases, they collected data relevant to the creation of the differential diagnosis, analysis of the history and physical exam, diagnostic justification, ordering tests; interpreting tests, and ranking of the most probable diagnosis. These data were compared with an expert-created scorecard, and detailed quantitative and qualitative feedback were generated and provided to the learners and instructors. OUTCOMES: Following an initial pilot study to troubleshoot the software, the authors conducted a second pilot study in which 2 instructors developed and provided 6 cases to 75 second-year medical students. The students completed 376 cases (average 5.0 cases per student), generating more than 40,200 data points that the software analyzed to inform individual learner formative feedback relevant to clinical reasoning skills. The instructors reported that the workload was acceptable and sustainable. NEXT STEPS: The authors are actively expanding the library of clinical cases and providing more students and schools with formative feedback in clinical reasoning using our tool. Further, they have upgraded the software to identify and provide feedback on behaviors consistent with premature closure, anchoring, and confirmation biases. They are currently collecting and analyzing additional data using the same software to inform validation and psychometric outcomes for future publications.

Quantifying the medical student learning curve for ECG rhythm strip interpretation using deliberate practice.

Objectives: Obtaining competency in medical skills such as interpretation of electrocardiograms (ECGs) requires repeated practice and feedback. Structured repeated practice and feedback for ECGs is likely not provided to most medical students, so skill development is dependent on opportunistic training during clinical rotations. Our aim was to describe: the amount of deliberate practice completed for learning ECG rhythm strip diagnoses in first year medical students, the learning curve for rhythm strip diagnosis, and student experiences with deliberate practice. Methods: First year medical students from two medical schools were provided with online rhythm strip practice cases. Diagnostic accuracy was measured throughout practice, and students were provided feedback for every case they completed. Total cases practiced and time spent practicing were correlated with their performance during practice and on an exam. Results: 314 of 384 (82%) students consented. The mean number of ECGs each student practiced was 59 (range 0-280), representing 18,466 total instances of deliberate practice. We generated mathematical models that accurately correlated both the number of cases practiced and time spent practicing, with diagnostic accuracy on an exam (p<0.001). For example, students would need to spend on average of 112 minutes and complete 34 practice cases to obtain 75% on an ECG rhythm strip exam. Student satisfaction was high using the online cases. Conclusions: We succeeded in delivering deliberate practice for ECG rhythm strip interpretation to a large cohort of students at 2 medical schools. We quantified a learning curve that estimates the number of cases and practice time required to achieve pre-determined levels of diagnostic accuracy. This data can help inform a competency-based approach to curriculum development.

Does self-modulated learning vs. algorithm-regulated learning of dermatology morphology affect learning efficiency of medical students?

BACKGROUND: Deliberate practice is an important method of skill acquisition and is under-utilized in dermatology training. We delivered a dermatologic morphology training module with immediate feedback for first year medical students. Our goal was to determine whether there are differences in accuracy and learning efficiency between self- regulated and algorithm-regulated groups. METHODS: First year medical students at the University of Calgary completed a dermatologic morphology module. We randomly assigned them to either a self-regulated arm (students removed cases from the practice pool at their discretion) or an algorithm-regulated arm (an algorithm determined when a case would be removed). We then administered a pre-survey, pre-test, post-test, and post-survey. Data collected included mean diagnostic accuracy of the practice sessions and tests, and the time spent practicing. The surveys assessed demographic data and student satisfaction. RESULTS: Students in the algorithm-regulated arm completed more cases than the self-regulated arm (52.9 vs. 29.3, p<0.001) and spent twice as much time completing the module than the self-regulated participants (34.3 vs. 17.0 min., p<0.001). Mean scores were equivalent between the algorithm- and self-regulated groups for the pre-test (63% vs. 66%, n = 54) and post-test (90% vs. 86%, n = 10), respectively. Both arms demonstrated statistically significant improvement in the post-test. CONCLUSION: Both the self-regulated and algorithm-regulated arms improved at post-test. Students spent significantly less time practicing in the self-directed arm, suggesting it was more efficient.

Subjective awareness of ultrasound expertise development: individual experience as a determinant of overconfidence.

Medical decision-making requires years of experience in order to develop an adequate level of competence to successfully engage in safe practice. While diagnostic and technical skills are essential, an awareness of the extent and limits of our own knowledge and skills is critical. The present study examines clinicians' subjective awareness in a diagnostic cardiac ultrasound task. Clinicians answered diagnostic and treatment related questions for a range of pathologies. Following these questions, clinicians indicated their level of confidence in their response. A comparison of response accuracy and confidence revealed that clinicians were generally overconfident in their responses. Critically, we observed that a clinician's overconfidence was negatively correlated with prior experience: clinicians that had more prior experience expressed less overconfidence in their performance such that some clinicians were in fact underconfident. We discuss the implications for training in medical education and decision-making.

Focused Critical Care Echocardiography: Development and Evaluation of an Image Acquisition Assessment Tool.

OBJECTIVES: Little attention has been placed on assessment tools to evaluate image acquisition quality for focused critical care echocardiography. We designed a novel assessment tool to objectively evaluate the image acquisition skills of critical care trainees learning focused critical care echocardiography and examined the tool for evidence of validity. DESIGN: Prospective observational study. SETTING: Medical-surgical ICUs at a tertiary care teaching hospital. SUBJECTS: Trainees in our critical care medicine fellowship program. INTERVENTIONS: Six trainees completed a focused critical care echocardiography training curriculum followed by performing 20 transthoracic echocardiograms on patients receiving invasive mechanical ventilation. At three assessment intervals (the 1st and 2nd examinations, 10th and 11th examinations, and 19th and 20th examinations), echocardiograms performed by trainees were compared with those of critical care physicians certified in echocardiography and scored according to the focused critical care echocardiography assessment tool. The primary outcome was an efficiency score (overall assessment tool score divided by examination time). Differences in mean efficiency scores between echocardiographers of differing skill levels and changes in trainees' mean efficiency scores with increasing focused critical care echocardiography experience were compared by using t tests. MEASUREMENTS AND MAIN RESULTS: On the initial assessment, mean efficiency scores (SD) for trainees and experienced physicians were 1.55 (0.95) versus 2.78 (1.38), respectively (p = 0.02), and for the second and third assessments, the corresponding efficiency ratings for trainees and experienced physicians were 2.48 (0.97) versus 4.55 (1.32) (p < 0.01) and 2.61 (1.37) versus 4.17 (2.12) (p = 0.04), respectively. CONCLUSIONS: Trainees' efficiency in focused critical care echocardiography image acquisition improved quickly in the first 10 studies, yet, it could not match with the performance of experienced physicians after 20 focused critical care echocardiography studies. The focused critical care echocardiography assessment tool demonstrated evidence of validity and could discern changes in trainees' image acquisition performance with increasing experience.

Canadian recommendations for critical care ultrasound training and competency.

OBJECTIVE: To achieve national consensus on standards of training, quality assurance and maintenance of competence for critical care ultrasound for intensivists and critical care trainees in Canada using recently published international training statements. DATA SOURCES: Existing internationally endorsed guidelines and expert opinion. DATA SYNTHESIS: In November 2013, a day-long consensus meeting was held with 15 Canadian experts in critical care ultrasound in which essential topics relevant to training ultrasound were discussed. CONCLUSIONS: Consensus was achieved to direct training curriculum, oversight, quality assurance and maintenance of competence for critical care ultrasound. In providing the first national guideline of its kind, these Canadian recommendations may also serve as a model of critical care ultrasound dissemination for other countries.

Interaction between fluids and vasoactive agents on mortality in septic shock: a multicenter, observational study.

OBJECTIVE: Fluids and vasoactive agents are both used to treat septic shock, but little is known about how they interact or the optimal way to administer them. We sought to determine how hospital mortality was influenced by combined use of these two treatments. DESIGN: Retrospective evaluation using multivariable logistic regression to evaluate the association between hospital mortality and categorical variables representing initiation of vasoactive agents and volumes of IV fluids given 0-1, 1-6, and 6-24 hours after onset, including interactions and adjusting for potential confounders. SETTING: ICUs of 24 hospitals in 3 countries. PATIENTS: Two thousand eight hundred forty-nine patients who survived more than 24 hours after after onset of septic shock, admitted between 1989 and 2007. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fluids and vasoactive agents had strong, interacting associations with mortality (p < 0.0001). Mortality was lowest when vasoactive agents were begun 1-6 hours after onset, with more than 1 L of fluids in the initial hour after shock onset, more than 2.4 L from hours 1-6, and 1.6-3.5 L from 6 to 24 hours. The lowest mortality rates were associated with starting vasoactive agents 1-6 hours after onset. CONCLUSIONS: The focus during the first hour of resuscitation for septic shock should be aggressive fluid administration, only thereafter starting vasoactive agents, while continuing aggressive fluid administration. Starting vasoactive agents in the initial hour may be detrimental, and not all of that association is due to less fluids being given with such early initiation of vasoactive agents.

In vitro study of patient's and physician's radiation exposure in the performance of epiduroscopy.

BACKGROUND AND OBJECTIVES: Epiduroscopy is a minimally invasive diagnostic and therapeutic technique, useful in the management of patients with back and leg pain. However, the dose of radiation exposure by fluoroscopy during epiduroscopy is not known. The endpoint of our study was to evaluate the amount of radiation exposure for patients and health care workers during epiduroscopy. METHODS: First, we measured the radiation dose during a 10-minute fluoroscopy exposure in humanoid models, which substituted for the patient and the physician. Second, we measured the duration of fluoroscopy during our clinical epiduroscopy in 14 patients and observed for radiation injury in these patients. RESULTS: In the humanoid models, the patient model skin exposure dose over a 10-minute period was measured as 238 mGy. The physician's exposure dose for 10 minutes was measured as 0.67 mGy outside the lead apron and 0.0084 mGy inside the lead apron. For the clinical epiduroscopic procedures, the average duration of fluoroscopy was 9 minutes and 26 seconds. No skin injuries in the patients were observed at a 1-month postprocedure assessment. CONCLUSIONS: The radiological dosages in the patient humanoid model were less than the threshold doses that could lead to organ injuries for 1 epiduroscopic procedure. However, care should be taken for cumulative exposures in repeated procedures.