Developing and Validating Entrustable Professional Activities (EPAs) for Rheumatology Fellowship Training Programs in Saudi Arabia: A Delphi Study.

Background: Entrustable professional activities (EPAs) define the core tasks that a graduating rheumatologist needs to perform independently in practice. The objective of this study was to develop and validate EPAs for rheumatology fellowship training programs in Saudi Arabia. Methods: Experts met to develop an initial set of potential end-of-training EPAs by conducting a comprehensive literature review of EPAs and studying the Saudi rheumatology fellowship curriculum. Then, to validate the EPAs, we conducted two rounds of the modified Delphi technique among rheumatology experts in Saudi Arabia. A response rate of 80% was considered and the minimum number of experts needed to be 25 to 30. Descriptive statistics were utilized to describe participants' demographic characteristics and group responses to each statement in all rounds. The experts were asked to rate the relevancy of each EPA using a 5-point Likert scale in both Delphi rounds. Results: In the preliminary phase, four rheumatologists developed an initial set of 36 core EPAs for rheumatology training program in Saudi Arabia. For the two-rounds Delphi techniques, 32 experts were invited to complete the study. The response rate of the first and second round were, 78.12% (25) and 93.75% (30), respectively. The first-round Delphi resulted in a robust consensus on 31 EPAs for rheumatology training. Five EPAs were excluded, and one new EPA was proposed. In the subsequent round, all 32 EPAs achieved strong consensus. The eliminated EPAs likely fell short in one or more of the following areas: relevance to rheumatology practice in Saudi Arabia, overlapping with other EPAs, or practical challenges in the implementation. Conclusion: We have developed and validated a core set of EPAs for rheumatology fellowship training programs in Saudi Arabia. Mapping and identifying milestones for these EPAs are essential steps to follow to enhance workplace curriculum development.

Weight Loss Effect of GLP-1 RAs With Endoscopic Bariatric Therapy and Bariatric Surgeries.

Background: Different treatment modalities are available for obesity management, including lifestyle changes, pharmacotherapy, endoscopic interventions, and surgeries. Limited evidence is available on the weight loss effect of combining glucagon-like peptide 1 receptor agonists (GLP-1 RAs) with endoscopic bariatric therapy (EBT) and bariatric surgeries (BS). Objectives: In this systematic review, we compared the weight loss effect and metabolic changes of combining GLP-1 RAs with EBT and BS. Methods: Literature searches were performed in the Cochrane Database of Systematic Review, Cochrane Central Register of Controlled Trials, Embase, PubMed, Google Scholar, and PRISMA databases. Only randomized control trials and retrospective studies were included. Results: A total of 11 studies was included. Nine studies compared BS with and without liraglutide and 2 compared EBT with and without liraglutide. Adding liraglutide to EBT or BS provided significant weight loss when compared with EBT or BS alone. When changes in weight were compared across the studies, EBT with liraglutide showed a weight loss effect comparable to the net weight loss (ie, nadir weight loss after BS-regained weight) achieved following BS alone. Conclusion: This review showcases a promising approach for managing obesity that combines GLP-1 RAs with EBT. This approach is expected to achieve shorter hospital stays, fewer side effects, and longer term weight loss benefits than BS alone. However, additional prospective studies with higher quality, more consistent outcome measures for weight loss and metabolic changes are needed to further evaluate the approach.

Computed Tomography Scan Overestimates the Size of Pericardial Effusion Compared to Echocardiography.

OBJECTIVE:  Pericardial effusion is not an uncommon finding in hospitalized patients. Many pericardial effusions are found incidentally through computed tomography (CT) performed for other indications. Echocardiography is usually ordered when an incidentally discovered pericardial effusion is found on the CT to examine the effect of the effusion on hemodynamics and to detect early signs of tamponade. However, in clinical practice, the discrepancy between CT and echocardiography regarding the size of pericardial effusions is common. The accuracy of CT in the evaluation of the size of pericardial effusions is not well-studied. Our study aims to evaluate the accuracy of CT in assessing the size of a pericardial effusion compared with the gold standard echocardiography. METHODS:  This is a retrospective study examining patients presenting to the University of Toledo Medical Center (UTMC) with pericardial effusions. One hundred and forty-one patient charts were reviewed and 45 subjects were excluded. Ninety-six patients in whom both CT and echocardiography were performed were enrolled in the final analysis. The time interval between both imaging modalities was limited to less than 14 days and no interventions on the effusion (e.g., pericardiocentesis) occurred in the time interval between the two imaging modalities. RESULTS:  The size of the pericardial effusion was assessed similarly between CT and echocardiography in 50% of the cases (48/96). In the other half of the study population, the results were discrepant; CT was found to overestimate the size of pericardial effusion in 44% of the cases (42/96). The agreement rate between the two modalities is significantly low kappa = 0.111, P = 0.028. The independent variables age, gender, body mass index (BMI), use of anticoagulants, and renal function had no effect on the agreement between CT and echocardiography. CONCLUSION:  Computerized tomography tends to overestimate the size of the pericardial effusion compared to echocardiography. Based on an incidental finding of pericardial effusion on CT scan, this discrepancy should be recognized prior to ordering an echocardiogram. Echocardiography can be considered in relevant clinical settings.

Cervical Spinal Osteomyelitis with Epidural Abscess following an Escherichia coli Urinary Tract Infection in an Immunocompetent Host.

Spinal epidural abscess (SEA) is uncommon with an incidence reported as 0.33-1.96 abscesses per 10,000 hospital admissions per year. Two-thirds of the cases were caused by Staphylococcus aureus. Escherichia coli (E. coli) is a less common cause of SEA, and it is usually after urinary tract infection in patient with preexisting risk factor. A 69-year-old male with a past medical history significant for prostatitis was admitted with fever, altered mental status, neck pain, progressive lower extremities weakness, and frequent falls for 7 days. Both blood and urine cultures grew E. coli. Lumbar puncture showed 94 RBCs, 24 WBCs (16% neutrophils and 46% lymphocytes), and elevated protein level at 1140 mg/dl with no bacteria. C-spine MRI showed epidural abscess along the anterior and right lateral margin of the cord causing cord compression from C5 through C7, anterior perivertebral abscess from C4 through T2, marrow edema involving C6 and C7 vertebral bodies with increased signal in the intervertebral disc space at C6-C7, and consistent with osteomyelitis and discitis. Anterior cervical decompression with evacuation of anterior epidural abscess with fusion was done. The culture from the epidural abscess grew E coli. A diagnosis of SEA should be considered in patients presenting with progressive weakness and neurological deficits following UTI and is to be confirmed by MRI. E. coli could be the culprit for epidural abscess and spine osteomyelitis even in immunocompetent patients.

Hemophagocytic Lymphohistiocytosis in the Elderly.

Hemophagocytic lymphohistiocytosis (HLH) is a rare disease of massive, dysregulated cytokine release and secondary multiorgan failure and is associated with high mortality. Primary HLH occurs predominately in infants and young children with a genetic predisposition. Acquired HLH is less well characterized and usually occurs in younger adults in the setting of severe inflammation triggered by infection or malignancy. Little is known about the disease in elderly. We report 3 patients >50 years old who presented with multiorgan failure and shock without an identifiable source and were ultimately diagnosed with acquired HLH. We performed a literature review of HLH in adults >50 years of age and identified an additional 68 cases. Mean age was 62 years, with male predominance. Most cases were triggered by infection (49%) followed by malignancy (27%). Nineteen patients were treated with the HLH-94 protocol, 11 received corticosteroids and the remainder received non-HLH specific interventions. Overall mortality was 62%.

Postthrombotic Syndrome: Long-Term Sequela of Deep Venous Thrombosis.

Postthrombotic syndrome is a common long-term complication of proximal lower extremity deep venous thrombosis, which not only significantly affects the quality of life of patients but also imposes a substantial financial burden on our healthcare system. Due to limited awareness and inability of physicians to recognize and treat this condition early, its prevalence is steadily increasing. In this article, we review the pathophysiology, the risk factors involved, diagnostic workup, and the various management options available to treat this condition.