Uremic Pericarditis with Cardiac Tamponade in a Patient on Hemodialysis.

Uremic pericardial effusion and pericarditis in end-stage kidney disease patients remain one of the causes responsible for high rates of morbidity and occasional mortality. While clinical presentation could be variable, clinicians should have a high index of suspicion for uremic pericarditis especially in patients who miss their dialysis sessions. We present a 77-year-old man with end-stage renal disease on dialysis diagnosed with pericarditis and large pericardial effusion complicated by cardiac tamponade and shock. He underwent urgent pericardiocentesis with clinical improvement. The course of the disease can be complicated by shock with multiorgan failure, particularly the liver. The presentation is relatively acute requiring a high level of suspicion, urgent diagnosis, and management to reduce mortality. As the geriatric population increases with associated comorbid conditions, it would be expected that patients undergoing dialysis would increase. Given the uncommon nature of the disease and how these patients have been managed by multiple specialties and care providers, it is important to consider dialysis-related complications in all patients with end-stage renal disease presenting with dyspnea.

Not Like the Textbook: An Atypical Case of Ectopic Pregnancy.

Ectopic pregnancy is a potentially life-threatening outcome of pregnancy that occurs with the implantation of an embryo outside of the endometrial cavity. Classically considered a "must not miss" diagnosis, ectopic pregnancy is a common emergency department presentation, associated with a symptom triad of amenorrhea, vaginal bleeding, and abdominal pain. However, varied presentations of ectopic pregnancy or lack of typical risk factors can complicate the evaluation and diagnosis of this condition. This case report describes an atypical presentation of ectopic pregnancy after a reported spontaneous abortion, in which the patient was initially discharged with a diagnosis of pelvic inflammatory disease. This case provides an illustration of ectopic pregnancy that presented without classically associated symptoms, and also highlights how anchoring bias and pre-emptive closure, among other cognitive biases, contributed to a missed diagnosis.

The effect of interconnections on gas adsorption in materials with spherical mesopores: A Monte Carlo simulation study.

Gas adsorption is a standard method for measuring pore-size distributions of nanoporous materials. This method is often based on assuming the pores as separate entities of a certain simple shape: slit-like, cylindrical, or spherical. Here, we study the effect of interconnections on gas adsorption in materials with spherical pores, such as three-dimensionally ordered mesoporous (3DOm) carbons. We consider interconnected systems with two, four, and six windows of various sizes. We propose a simple method based on the integration of solid-fluid interactions to take into account these windows. We used Monte Carlo simulations to model argon adsorption at the normal boiling point and obtained adsorption isotherms for the range of systems. For a system with two windows, we obtained a remarkably smooth transition from the spherical to cylindrical isotherm. Depending on the size and number of windows, our system resembles both spherical and cylindrical pores. These windows can drastically shift the point of capillary condensation and result in pore-size distributions that are very different from the ones based on a spherical pore model. Our results can be further used for modeling fluids in a system of interconnected pores using Monte Carlo and density functional theory methods.

OR fire virtual training simulator: design and face validity.

BACKGROUND: The Virtual Electrosurgical Skill Trainer is a tool for training surgeons the safe operation of electrosurgery tools in both open and minimally invasive surgery. This training includes a dedicated team-training module that focuses on operating room (OR) fire prevention and response. The module was developed to allow trainees, practicing surgeons, anesthesiologist, and nurses to interact with a virtual OR environment, which includes anesthesia apparatus, electrosurgical equipment, a virtual patient, and a fire extinguisher. Wearing a head-mounted display, participants must correctly identify the "fire triangle" elements and then successfully contain an OR fire. Within these virtual reality scenarios, trainees learn to react appropriately to the simulated emergency. A study targeted at establishing the face validity of the virtual OR fire simulator was undertaken at the 2015 Society of American Gastrointestinal and Endoscopic Surgeons conference. METHODS: Forty-nine subjects with varying experience participated in this Institutional Review Board-approved study. The subjects were asked to complete the OR fire training/prevention sequence in the VEST simulator. Subjects were then asked to answer a subjective preference questionnaire consisting of sixteen questions, focused on the usefulness and fidelity of the simulator. RESULTS: On a 5-point scale, 12 of 13 questions were rated at a mean of 3 or greater (92%). Five questions were rated above 4 (38%), particularly those focusing on the simulator effectiveness and its usefulness in OR fire safety training. A total of 33 of the 49 participants (67%) chose the virtual OR fire trainer over the traditional training methods such as a textbook or an animal model. CONCLUSIONS: Training for OR fire emergencies in fully immersive VR environments, such as the VEST trainer, may be the ideal training modality. The face validity of the OR fire training module of the VEST simulator was successfully established on many aspects of the simulation.

Virtual Airway Skills Trainer (VAST) Simulator.

This paper presents a simulation of Virtual Airway Skill Trainer (VAST) tasks. The simulated tasks are a part of two main airway management techniques; Endotracheal Intubation (ETI) and Cricothyroidotomy (CCT). ETI is a simple nonsurgical airway management technique, while CCT is the extreme surgical alternative to secure the airway of a patient. We developed identification of Mallampati class, finding the optimal angle for positioning pharyngeal/mouth axes tasks for ETI and identification of anatomical landmarks and incision tasks for CCT. Both ETI and CCT simulators were used to get physicians' feedback at Society for Education in Anesthesiology and Association for Surgical Education spring meetings. In this preliminary validation study, total 38 participants for ETI and 48 for CCT performed each simulation task and completed pre and post questionnaires. In this work, we present the details of the simulation for the tasks and also the analysis of the collected data from the validation study.

A hierarchical task analysis of cricothyroidotomy procedure for a virtual airway skills trainer simulator.

BACKGROUND: Despite the critical importance of cricothyroidotomy (CCT) for patient in extremis, clinical experience with CCT is infrequent, and current training tools are inadequate. The long-term goal is to develop a virtual airway skills trainer that requires a thorough task analysis to determine the critical procedural steps, learning metrics, and parameters for assessment. METHODS: Hierarchical task analysis is performed to describe major tasks and subtasks for CCT. A rubric for performance scoring for each task was derived, and possible operative errors were identified. RESULTS: Time series analyses for 7 CCT videos were performed with 3 different observers. According to Pearson's correlation tests, 3 of the 7 major tasks had a strong correlation between their task times and performance scores. CONCLUSIONS: The task analysis forms the core of a proposed virtual CCT simulator, and highlights links between performance time and accuracy when teaching individual surgical steps of the procedure.

A computerized system for the application of Basso, Beattie and Bresnahan scale in Wistar rats.

OBJECTIVES: To develop and test a computer program to assist researchers in assigning scores in the application of the Basso, Beattie and Bresnahan (BBB) scale and to compare these scores when doing so in free, targeted and automated computer-assisted modes. METHOD: To test the program, the participants used the Impactor methodology recommended by the New York University (USA), in which 12 Wistar rats submitted to spinal cord injury were filmed on the 28(th) day after the injury. Eight researchers from the Laboratory of Medical Investigation, Faculdade de Medicina da Universidade de São Paulo, SP, Brazil took part in the study. The two heads of the laboratory, with 15 years of experience in the application of the scale, were considered the gold standard. RESULTS: The results of the scale application were not significantly different in relation to the gold standard, considering the mean of the evaluators in each method: free, targeted and automated form (with the help of the computer). CONCLUSIONS: The application of the BBB scale in the automated mode, using the computer program, did not present any difference in relation to the gold standard for all the evaluators. Level of Evidence II, Diagnostic Studies.

A computerized system for the application of Basso, Beattie and Bresnahan scale in Wistar rats

OBJECTIVES: To develop and test a computer program to assist researchers in assigning scores in the application of the Basso, Beattie and Bresnahan (BBB) scale and to compare these scores when doing so in free, targeted and automated computer-assisted modes. METHOD: To test the program, the participants used the Impactor methodology recommended by the New York University (USA), in which 12 Wistar rats submitted to spinal cord injury were filmed on the 28th day after the injury. Eight researchers from the Laboratory of Medical Investigation, Faculdade de Medicina da Universidade de São Paulo, SP, Brazil took part in the study. The two heads of the laboratory, with 15 years of experience in the application of the scale, were considered the gold standard. RESULTS: The results of the scale application were not significantly different in relation to the gold standard, considering the mean of the evaluators in each method: free, targeted and automated form (with the help of the computer). CONCLUSIONS: The application of the BBB scale in the automated mode, using the computer program, did not present any difference in relation to the gold standard for all the evaluators. Level of Evidence II, Diagnostic Studies. .

Computer-aided systematized approach to pediatric ECG analysis.

BACKGROUND: In pediatric electrocardiography (ECG), the correct classification of segments in the medical record is subjected to various components. A conventional analysis based either on the cardiologist's skills or a quick reference to a standard normality table may lead to mistakes and to an incorrect final medical diagnosis. In this study, the evaluation of 12 specific ECG segments (ES) is defined as segmental analysis (SA). We hypothesized that a computer-aided SA can provide better results for a correct classification of pediatric ECGs, compared to the conventional analysis. This study aims to evaluate the accuracy of a computer-aided SA ECG diagnosis of pediatric patients by cardiologists. METHODS: To validate the software, we selected four normal and one altered ECG as references, all with concordant reports given by two cardiologists using manual planimetry. Nineteen cardiology experts independently examined each of the five standard pediatric ECGs twice. First, the ECG was analyzed in the conventional form. Subsequently, the participants evaluated ECGs with our proposed computer-aided AS, by measuring the 12 specific ES in the grid paper and having their values entered into a custom-made software, in order to compare them with normality standards. RESULTS: The computer-aided SA reduced ECG misreading or ECG misinterpretation errors by 83%. It also showed a more uniform, high-quality analysis of all ES (minimum of 92% correctly reviewed segments from normal pediatric ECGs) by all the participant cardiologists. CONCLUSIONS: We consider the computer-aided SA for ECG evaluation in pediatric cardiology an efficient and safe complementary method.

Estudo comparativo entre a avaliaçao livre, dirigida e automatizada na assistência ao diagnóstico eletrocardiográfico em crianças e adolescentes / Comparative study among the free evaluation, guided and automatized in the assistance to the electrocardiographic diagnosis in children and adolescents

Para avaliar a precisão da análise segmentar em eletrocardiografia pediátrica por cardiologistas, três diferentes métodos foram confrontados. No primeiro, avaliação livre, a normalidade segmentar é questionada e o entrevistado tem liberdade para aferição métrica, caso necessário. No segundo, avaliação dirigida, a mesma pergunta é formulada, porém com a imposição de uma aferição prévia do segmento No terceiro, avaliação automatizada, apenas a aferição é solicitada e submetida a um software de interpretação segmentar para ECG pediátrico com uma tabela de normalidade. As respostas foram comparadas às análises de dois cardiologistas (controle). O viés interpretativo foi significativamente menor na avaliação automatizada e a aferição precedente não modificou as interpretações não automatizadas...

To establish the precision of segmental analyses in pediatric electrocardiography by cardiologists, three different methods were confronted. In the first one, free assessment, the segment normality is questioned and the practitioner is allowed to quantitatively check the ECG, if needed. In the second, guided assessment, the same question is formulated, but the preliminary inspection of the segment is mandatory. In the third, automated assessment, only the inspection is requested and submitted to segmental interpretation software for pediatric ECG with an embedded table of normality. All answers were compared to the analysis of two cardiologists (control). Interpretative bias was significantly lower in the automated assessment and preceding inspection has not modified the non automated interpretations...

Accumulation of chylomicron remnants and impaired vascular reactivity occur in subjects with isolated low HDL cholesterol: effects of niacin treatment.

Fasting hypertriglyceridemia relates with high-density lipoprotein (HDL) cholesterol, but it is not known whether low HDL cholesterol is associated with disturbances of chylomicron metabolism. To clarify this issue this metabolism was studied in subjects with low HDL cholesterol together with vascular reactivity and evaluation of no-flush niacin treatment. Thirty men with HDL < 1.04 mmol/L and no other risk factors for coronary artery disease (CAD) and 11 normal controls with HDL > 1.04 mmol/L were studied. The plasma kinetics of a chylomicron-like emulsion labeled with 14C-cholesterol oleate (CO) and 3H-triolein (TG) was determined and the fractional clearance rate (FCR, min(-1)) was calculated. Vascular reactivity was evaluated using high-resolution ultrasonography. CO FCR was markedly reduced in the low HDL group compared to controls (3.6 x 10(-3) +/- 5.1 x 10(-3) min(-1) versus 12.2 x 10(-3) +/- 8.4 x 10(-3) min(-1), p < 0.001) but TG FCR was similar. Flow-mediated dilation (FMD) was diminished in low HDL (7.4 +/- 4.1 versus 12.8 +/- 4.6%, p < 0.001), whereas nitrate-mediated dilation was similar. Twenty-two low HDL subjects with reduced FMD were randomized into two groups, one given 1.5 g/day niacin and a placebo group. After 3-month treatment, plasma lipids and chylomicron kinetics were not changed by niacin treatment but FMD improved to normal values (5.44 +/- 1.89 to 11.13 +/- 3.4%, p < 0.01). In conclusion, isolated low HDL cholesterol subjects may also bear chylomicron remnant accumulation and endothelial dysfunction, which highlight the importance of their preventive treatment.

Nueva ortesis para el tratamiento del dedo en martillo de origen traumático: estudio preliminar / New orthesis for the treatment of mallet finger of traumatic origin: a preliminary study

Se presentó una serie de 10 pacientes del sexo masculino con dedo en martillo traumático, comprendidos en un grupo de edad entre 20 y 30 años, los que fueron tratados con una ortesis de nueva creación por un período de 4 semanas, que llegaron a la curación sin secuelas. Se revisó cuidadosamente la literatura internacional y nacional, y no se encontró este modelo. Se realizó una artesis de forma manual y sencilla con un kirschner de 1 mm, la cual puede hacerse en el cuerpo de guardia por el ortopédico y no retardar el tratamiento del paciente; además, solo se inmovilizó la articulación interfalángica distal y así se quedó libre la articulación interfalángica proximal sin dejar rigidez de esta, lo cual ocurre con el tratamiento de urgencia con yeso. Con este trabajo de pretende demostrar que el tratamiento conservador de urgencia de inmovilizar la articulación interfalángica distal para el Mallet Finger traumático, es el ideal

Nueva ortesis para el tratamiento del dedo en martillo de origen traumático: estudio preliminar / New orthesis for the treatment of mallet finger of traumatic origin: a preliminary study

Se presentó una serie de 10 pacientes del sexo masculino con dedo en martillo traumático, comprendidos en un grupo de edad entre 20 y 30 años, los que fueron tratados con una ortesis de nueva creación por un período de 4 semanas, que llegaron a la curación sin secuelas. Se revisó cuidadosamente la literatura internacional y nacional, y no se encontró este modelo. Se realizó una artesis de forma manual y sencilla con un kirschner de 1 mm, la cual puede hacerse en el cuerpo de guardia por el ortopédico y no retardar el tratamiento del paciente; además, solo se inmovilizó la articulación interfalángica distal y así se quedó libre la articulación interfalángica proximal sin dejar rigidez de esta, lo cual ocurre con el tratamiento de urgencia con yeso. Con este trabajo de pretende demostrar que el tratamiento conservador de urgencia de inmovilizar la articulación interfalángica distal para el Mallet Finger traumático, es el ideal(AU)