When a calorie isn't just a calorie: a revised look at nutrition in critically ill patients with sepsis and acute kidney injury.

PURPOSE OF REVIEW: To discuss how nutritional management could be optimized to promote protective metabolism in sepsis and associated acute kidney injury. RECENT FINDINGS: Recent evidence suggests that sepsis is a metabolically distinct critical illness and that certain metabolic alterations, such as activation of fasting metabolism, may be protective in bacterial sepsis. These findings may explain the lack of survival benefit in recent randomized controlled trials of nutrition therapy for critical illness. These trials are limited by cohort heterogeneity, combining both septic and nonseptic critical illness, and the use of inaccurate caloric estimates to determine energy requirements. These energy estimates are also unable to provide information on specific substrate preferences or the capacity for substrate utilization. As a result, high protein feeding beyond the capacity for protein synthesis could cause harm in septic patients. Excess glucose and insulin exposures suppress fatty acid oxidation, ketogenesis and autophagy, of which emerging evidence suggest are protective against sepsis associated organ damage such as acute kidney injury. SUMMARY: Distinguishing pathogenic and protective sepsis-related metabolic changes are critical to enhancing and individualizing nutrition management for critically ill patients.

Perceptions of X+Y Scheduling Among Combined Internal Medicine-Pediatrics Residency Trainees: A Qualitative Program Evaluation.

OBJECTIVE: The study aims to elicit perceived benefits and downsides of X+Y scheduling for combined Internal Medicine-Pediatrics (Med-Peds) residents via focus groups. METHODS: Five focus groups were conducted with Med-Peds residents in participating programs which utilized X+Y scheduling. Onefocus group was held per participating institution. Each focus group was facilitated by a chief resident from a different participating institution. Questions were developed by the study team after a review of the literature and local experience with X+Y scheduling and included open-ended questions. Focus groups were recorded and transcribed. Transcripts were reviewed by study team members, and representative themes and quotes were presented. The main outcome was to evaluate the perceived benefits and downsides of X+Y scheduling for Med-Peds. RESULTS: Results from four of the five focus groups were fully reviewed. Themes regarding the benefits of X+Y scheduling included (1) improved inpatient and outpatient experience, (2) predictability in schedule which improved wellness, and (3) longitudinal time for career exploration. Downsides of X+Y scheduling were highlighted as well including (1) condensing too many experiences into Y time and (2) challenges that exist when categorical medicine and pediatrics programs use different block schedules. CONCLUSIONS: X+Y schedules create potential solutions for longstanding barriers to medical education and notably conflict with inpatient and outpatient responsibilities. Our data shows similar benefits to X+Y scheduling for combined residents as for their categorical colleagues and sheds light on some unique considerations for combined programs and trainees. Additional studies should continue to assess the effect of X+Y scheduling on our combined trainees.

Good Intentions to Treat.

Good Intentions to Treat This Stats, STAT! animated video explores common approaches to analyzing data from randomized controlled trials, including intention-to-treat, per-protocol, and as-treated analyses.

Fibronectin glomerulopathy: an unusual cause of adult-onset nephrotic syndrome.

We report the case of a 50-year-old woman with nephrotic-range proteinuria and lobular glomerulopathy on kidney biopsy. Homogenous glomerular deposits were non-immune reactive, but immunofluorescence microscopy for fibronectin was strongly positive. Ultrastructurally, the deposits were granular with focal fibril formation, leading to a diagnosis of fibronectin glomerulopathy. Mutational analysis revealed a heterozygous missense mutation in fibronectin (leading to the tyrosine at amino acid 973 being replaced by cysteine [Y973C]), confirming the diagnosis. This mutation affects Hep-III, one of the heparin-binding domains of fibronectin, and results in functional abnormalities.

A 22-Year-Old Man Coughs Blood.

A 22-Year-Old Man Coughs BloodA 22-year-old man sought evaluation after coughing up foul-smelling, brown sputum mixed with bright-red blood. Symptoms were preceded by chest pain in the left parasternal region that was worse on deep inspiration. Using questions, physical examination, and testing, an illness script for the presentation emerges. The differential is refined until a final diagnosis is made.

Mentoring Black Men in Medicine.

In recent years, there have been multiple publications about the dearth of Black men in medicine. Appreciating the fact that underrepresented minority physicians disproportionately care for America's underserved communities, the lack of diversity in health care is particularly disturbing. Of imminent concern is the critical shortage of Black men doctors. In this Perspective, the authors contend that while mentoring is often considered among the most important strategies to increase the number of Black men in medicine, unique challenges in this demographic can diminish its effectiveness. Among these challenges are below average primary school educational experiences and a general mistrust of society on the part of Black men, as well as difficulties overcoming stereotypes and social biases that others hold against them. Furthermore, acknowledging that mentorship is paramount in achieving success in the medical field, the authors provide a framework to assist mentors in recognizing and addressing situations and obstacles that may disrupt the mentoring relationship and hinder its potential to best serve Black men pursuing advancement in medicine. This framework is represented by the acronym RACE: Reluctance to discuss race, Access to mentors, Cultural mistrust and racial concordance, and Empathy.

Multidimensional Interactive Radiology Report and Analysis: Standardization of workflow and reporting for renal mass tracking and quantification.

A conventional radiology report primarily consists of a large amount of unstructured text, and lacks clear, concise, consistent and content-rich information. Hence, an area of unmet clinical need consists of developing better ways to communicate radiology findings and information specific to each patient. Here, we design a new workflow and reporting system that combines and integrates advances in engineering technology with those from the medical sciences, the Multidimensional Interactive Radiology Report and Analysis (MIRRA). Until recently, clinical standards have primarily relied on 2D images for the purpose of measurement, but with the advent of 3D processing, many of the manually measured metrics can be automated, leading to better reproducibility and less subjective measurement placement. Hence, we make use this newly available 3D processing in our workflow. Our pipeline is used here to standardize the labeling, tracking, and quantifying of metrics for renal masses.