Education curriculum assessment for teaching electrocardiography: Rationale and design for the prospective, international, randomized controlled EDUCATE trial.

BACKGROUND: Electrocardiogram (ECG) interpretation training is a fundamental component of medical education across disciplines. However, the skill of interpreting ECGs is not universal among medical graduates, and numerous barriers and challenges exist in medical training and clinical practice. An evidence-based and widely accessible learning solution is needed. DESIGN: The EDUcation Curriculum Assessment for Teaching Electrocardiography (EDUCATE) Trial is a prospective, international, investigator-initiated, open-label, randomized controlled trial designed to determine the efficacy of self-directed and active-learning approaches of a web-based educational platform for improving ECG interpretation proficiency. Target enrollment is 1000 medical professionals from a variety of medical disciplines and training levels. Participants will complete a pre-intervention baseline survey and an ECG interpretation proficiency test. After completion, participants will be randomized into one of four groups in a 1:1:1:1 fashion: (i) an online, question-based learning resource, (ii) an online, lecture-based learning resource, (iii) an online, hybrid question- and lecture-based learning resource, or (iv) a control group with no ECG learning resources. The primary endpoint will be the change in overall ECG interpretation performance according to pre- and post-intervention tests, and it will be measured within and compared between medical professional groups. Secondary endpoints will include changes in ECG interpretation time, self-reported confidence, and interpretation accuracy for specific ECG findings. CONCLUSIONS: The EDUCATE Trial is a pioneering initiative aiming to establish a practical, widely available, evidence-based solution to enhance ECG interpretation proficiency among medical professionals. Through its innovative study design, it tackles the currently unaddressed challenges of ECG interpretation education in the modern era. The trial seeks to pinpoint performance gaps across medical professions, compare the effectiveness of different web-based ECG content delivery methods, and create initial evidence for competency-based standards. If successful, the EDUCATE Trial will represent a significant stride towards data-driven solutions for improving ECG interpretation skills in the medical community.

Hemorrhagic pancreatic pseudocyst: A rare complication.

Pancreatic pseudocysts are seen both in acute and chronic pancreatitis. Prevalence of pancreatic pseudocyst in chronic pancreatitis is 20% to 40% and is most commonly seen in alcoholic chronic pancreatitis. Intracystic hemorrhage from a pseudoaneurysm is a rare and potentially a lethal complication of pancreatic pseudocyst with an incidence of less than 10%. We herein present a case of a 42-year-old male with a past medical history of chronic alcoholic pancreatitis, stable pseudocyst in the tail of pancreas, alcohol abuse and seizures who presented with abdominal pain and acute anemia had this rare complication of hemorrhagic pseudocyst. The diagnostic modalities used to diagnose hemorrhagic pseudocyst are ultrasound with color doppler, CT with contrast, digital subtraction angiography and angiography. Angiographic embolization of the culprit artery is the preferred treatment of choice in the treatment of pseudoaneurysms. It is important for early recognition and treatment of this complication as the mortality can be as high as 40%.

Varicella zoster presenting as cranial polyneuropathy.

Cranial polyneuropathy is commonly caused by Lyme disease. We discuss the case of a man who presented with cranial nerve deficits causing dysphagia, dysphonia and facial weakness. This diagnostic dilemma stemmed from a workup that ruled out Lyme and vascular causes leading to an expanded search for infectious explanations, which revealed varicella zoster in the cerebrospinal fluid. On review, this phenomenon is rarely reported, but has been observed with a number of herpes family viruses. In emergency department settings, clinical suspicion should be raised for VZV infection even in the absence of rash in patients that present with multiple cranial nerve palsies.

Review of potential drug interaction between Oseltamivir and Warfarin and why it is important for emergency medicine physicians.

Oseltamivir is a very commonly prescribed anti-viral medication by the Emergency Medicine (EM) physicians for the prophylactic and therapeutic treatment of Influenza infection. While the drug interaction of Warfarin with various antibiotics is known, the drug interaction between Oseltamivir and Warfarin is not common. We present a case where an 83-year female patient, on Warfarin for Pulmonary Embolism, had worsening of coagulopathy after she was started on Oseltamivir. The INR was monitored daily in our patient and Warfarin was stopped when the INR became supra-therapeutic. Our patient did not have any minor or major bleeding complication. This is the first reported case of Oseltamivir related worsening coagulopathy in patient on Warfarin to the best of our knowledge. Keeping in mind the possible interaction between the two as it was evident in our case and few other published reports, we recommend monitoring the INR closely in patients using Warfarin after they are started on Oseltamivir therapy.

EDUCATE: An international, randomized controlled trial for teaching electrocardiography.

INTRODUCTION: Despite the critical role of electrocardiograms (ECGs) in patient care, evident gaps exist in ECG interpretation competency among healthcare professionals across various medical disciplines and training levels. Currently, no practical, evidence-based, and easily accessible ECG learning solution is available for healthcare professionals. The aim of this study was to assess the effectiveness of web-based, learner-directed interventions in improving ECG interpretation skills in a diverse group of healthcare professionals. METHODS: In an international, prospective, randomized controlled trial, 1206 healthcare professionals from various disciplines and training levels were enrolled. They underwent a pre-intervention test featuring 30 12-lead ECGs with common urgent and non-urgent findings. Participants were randomly assigned to four groups: (i) practice ECG interpretation question bank (question bank), (ii) lecture-based learning resource (lectures), (iii) hybrid question- and lecture-based learning resource (hybrid), or (iv) no ECG learning resources (control). After four months, a post-intervention test was administered. The primary outcome was the overall change in ECG interpretation performance, with secondary outcomes including changes in interpretation time, self-reported confidence, and accuracy for specific ECG findings. Both unadjusted and adjusted scores were used for performance assessment. RESULTS: Among 1206 participants, 863 (72 %) completed the trial. Following the intervention, the question bank, lectures, and hybrid intervention groups each exhibited significant improvements, with average unadjusted score increases of 11.4 % (95 % CI, 9.1 to 13.7; P<0.01), 9.8 % (95 % CI, 7.8 to 11.9; P<0.01), and 11.0 % (95 % CI, 9.2 to 12.9; P<0.01), respectively. In contrast, the control group demonstrated a non-significant improvement of 0.8 % (95 % CI, -1.2 to 2.8; P=0.54). While no differences were observed among intervention groups, all outperformed the control group significantly (P<0.01). Intervention groups also excelled in adjusted scores, confidence, and proficiency for specific ECG findings. CONCLUSION: Web-based, self-directed interventions markedly enhanced ECG interpretation skills across a diverse range of healthcare professionals, providing an accessible and evidence-based solution.

Negative anion gap metabolic acidosis in salicylate overdose--a zebra!

Salicylate poisoning classically results in an increased anion gap metabolic acidosis. We discuss a case of normal anion gap metabolic acidosis despite elevated serum salicylate concentration. This diagnostic dilemma stemmed from aberrant reading of salicylate ions by analyzer electrodes as chloride ions leading to falsely negative anion gap. On review, this phenomenon is found to be possible with a number of commonly used analyzers. In emergency department settings, high level of clinical suspicion for salicylate poisoning should be maintained, and metabolic acidosis with normal anion gap should not be used to rule out salicylate overdose. This can prevent significant avoidable morbidity and mortality.

Hospitalist perspective on pandemic related clinical and administrative changes: a cross sectional survey study.

OBJECTIVE: Hospitalists have played a leading role in caring for hospitalized COVID-19 patients. Many clinical and administrative changes occurred in hospitals to meet the varied pandemic needs. We surveyed hospitalists to understand their perspective on pandemic-related changes in technology, models of care, administration and leadership, impact on personal lives, and which of these changes should be continued versus reverting to pre-pandemic practices. METHODS: A 30-question survey was distributed to hospitalists working across the United States between 6 April 2022 to 16 May 2022. Baseline demographics were measured, and post-pandemic perspectives related to changes were analyzed. Perspectives were measured using a 5-point Likert scale and responses were categorized into 'agree' and 'did not agree' for analysis. Variation was assessed using Chi-square or Fisher exact tests. Open-ended questions were reported following qualitative content analysis organized into themes and reported as frequency. RESULTS: 177 respondents (39%) completed the survey. Nearly three-fourths favored hybrid meetings, and two-thirds preferred to continue new models of care. Nearly 90% desired more family and leisure time, continued wellness, and support services, and resumption of social gatherings. No major differences in perspectives were noted between hospitalists at teaching facilities and non-teaching facilities except for resuming protected time for non-clinical activities in those from teaching facilities (83.0% vs 62.5%). Respondents less than age 50 were more likely to prefer virtual meetings (59.0% vs 31.3%). Content analysis of open-ended questions resulted in different themes for each question. Respondents favored more work-life balance and less administrative and logistical work burden. CONCLUSIONS: Hospitalists preferred to continue the use of technology and new models of care even in the post-pandemic period and express a desire for more work-life balance and less administrative and logistical work burden.

Management dilemmas in restarting anticoagulation after gastrointestinal bleeding.

Systemic anticoagulants are widely prescribed to prevent and treat thromboembolism, among other indications. A common complication of using these agents is gastrointestinal bleeding. While early resumption of anticoagulants after the bleeding has resolved can increase the risk of rebleeding, delayed resumption puts the patient at increased risk of thromboembolic events and mortality. There is limited data on this topic to guide clinicians on resuming anticoagulation after hospitalization for gastrointestinal bleeding and to educate patients regarding the subsequent risks of recurrent gastrointestinal bleeding, thromboembolism, and mortality. The optimal time to resume anticoagulation is also unknown. This review summarizes the existing literature and available data on the commonly encountered dilemma of restarting anticoagulation therapy after hospitalization for gastrointestinal bleeding.

Impact of Structured and Scheduled Family Meetings on Satisfaction in Patients Admitted to Hospitalist Service.

Effective communication is key to patient satisfaction. Family meetings been shown to be effective in other settings such as critical care and palliative medicine. We evaluated the impact of scheduled and structured family meetings on patients admitted to the hospitalist service in terms of satisfaction with care delivery. More patients in the intervention group reported better understanding of their diagnosis, treatment plan, medications, and discharge plan. Based on these results, we advocate for structured and scheduled family meetings to be implemented as a communication tool for selected patients on the hospital medicine service to improve patient experience and satisfaction.

Asymptomatic Tumor Thrombus in the Left Atrium from Squamous Cell Carcinoma.

A 67-year-old female patient presented asymptomatically for further evaluation of a chest mass. Other than significant smoking history, the patient had been healthy with a recently treated case of uncomplicated pneumonia. The mass originated in the aortopulmonary window of the left mediastinum and invaded proximally into the left superior pulmonary vein and subsequently into the left atrium. The mass protrusion into the mitral valve occupied 50% of the left atrium space but showed no clinical symptoms of a valvular blockade. Poorly differentiated squamous cell carcinoma was identified upon biopsy. These findings of a primary lung tumor with atrial extension in an asymptomatic patient point to the importance of age-appropriate screening and standardization treatment modalities.

Eyes As the Window to Syphilis: A Rare Case of Ocular Syphilis As the Initial Presentation of Syphilis.

In the pre-antibiotic era, neurosyphilis (NS) was common, occurring in 34% of patients with syphilis. Currently, there has been a rising trend in syphilis with HIV-infected patients being more prone to develop NS. Ocular involvement is very rare in NS and accounts for only 1%-5% of the cases in the United States. We report the case of a 53-year-old male with a past medical history of gastroesophageal reflux disease and hyperlipidemia who presented to his ophthalmologist for blurred vision in both eyes. He had been noticing a black spot in the visual field of his left eye for two weeks. He had also noticed a rash on his forearms. His past and social history was significant for treated Lyme disease, having pet cats. He identified as a heterosexual male, married, and with five children. However, on further history taking, he reported a homosexual exposure about five years prior. He denied any history of genital ulcer or penile discharge. On examination at the ophthalmology clinic, he was found to have a visual acuity of 20/20 right eye and 20/100 left eye. Posterior segment examination of the both eyes showed subtle neuritis and vasculitis. Fundus photography revealed subtle neuroretinitis bilaterally. Work up was initiated for inflammatory and infectious causes. His rapid plasma reagin and fluorescent treponemal antibody absorption showed positive titers for syphilis. His presentation was most consistent with ocular syphilis. A lumbar puncture (LP) was done with Venereal Disease Research Laboratory (VDRL) positivity in the spinal fluid. He was therefore initiated on intravenous (IV) penicillin four million units every four hours for 14 days. His ophthalmology follow-up after one month showed both subjective and objective improvement in his visual symptoms. He also followed with the infectious disease team and a repeat LP done three months later showed nonreactive VDRL in cerebrospinal fluid (CSF). Ocular syphilis is increasing in incidence. Clinical presentation is variable, and a high index of suspicion with a low threshold for serological testing are important as early treatment can reverse retinal changes and restore visual acuity. There is a recommendation for CSF examination in all patients with ocular syphilis including HIV-negative cases. There have been studies showing a high CSF abnormal rate in HIV-negative patients with ocular syphilis. The recommended treatment for NS is aqueous crystalline penicillin G (18 to 24 million units per day, administered as three to four million units IV every four hours, or 24 million units daily as a continuous infusion) for 10 to 14 days. Follow-up is a key component of management with neurological examination and LP for CSF VDRL performed three months after treatment and every six months after, until the CSF is nonreactive for VDRL with normal white blood cell count. It is important to be cognizant of the rising trend of ocular syphilis, even in HIV-negative individuals. Early treatment is time sensitive to preventing permanent vision loss. Our case also emphasizes on thorough history taking, even for patients who appear to be at a low risk for sexually transmitted infections.

Acute on Chronic Immune Thrombocytopenia as a Cause of Thrombocytopenia in Sepsis.

Immune thrombocytopenia (ITP) is a diagnosis of exclusion and can be challenging at times to make the diagnosis. We herein present a case of a 73-year-old male with a history of chronic ITP, who presented to the hospital with sepsis and developed thrombocytopenia. His thrombocytopenia did not improve with resolution of sepsis but improved with ITP treatment including immunoglobulins and steroids. Platelet-associated IgG antibody levels are inversely proportional to platelet counts. The antibody levels are increased in sepsis. We would like to highlight that other causes of thrombocytopenia should also be considered in sepsis.

A Curious Case of Hypervitaminosis D.

The growing awareness of the beneficial health effects of vitamin D supplementation, the commonality of vitamin D deficiency, and the over-the-counter availability of vitamin D supplements has resulted in a renewed interest in vitamin D supplementation among patients as well as health care providers. We present a case of vitamin D toxicity (VDT) in a patient following self-medication with mega doses that far exceeded the prescribed dosage. He presented to us with acute kidney injury (AKI) and elevated serum 25(OH)-vitamin D levels. He was treated with intravenous hydration, loop diuretics, and prednisone and had a clinical and biochemical improvement as reflected in his labs. We suggest that physicians and health care providers be made aware of this commonly overlooked side-effect of vitamin D supplementation and the importance of regular blood levels to titrate the dose accordingly. At the same time, it is important that the public is made aware of the ill-effects of self-medicating on large doses of vitamins.