Reliability and reproducibility of the venous excess ultrasound (VExUS) score, a multi-site prospective study: validating a novel ultrasound technique for comprehensive assessment of venous congestion.

Though the novel venous excess ultrasound (VExUS) score is increasingly used as a noninvasive means of venous congestion measurement, the inter-rater reliability (IRR), inter-user reproducibility (IUR), and utility of concurrent ECG have not been evaluated. We conducted a multicenter study of the IRR, IUR, and utility of ECG for VExUS interpretation between four attending physicians of diverse specialties, reporting the Kappa statistic (KS) and Intraclass Correlation Coefficient (ICC) for IRR and IUR for scans with and without ECG. Eighty-four paired VExUS exams from 42 patients, 60 of which had a concurrent ECG tracing, were interpreted. They showed substantial IRR, with a KS of 0.71 and ICC of 0.83 for the overall VExUS grade (p < 0.001), and IUR, with a KS 0.63 and ICC of 0.8. There was greater agreement among images with an ECG tracing. These results suggest that ECG-augmented VExUS may be a reliable and reproducible measure interpretable by clinicians with diverse backgrounds.

Monitoring the venous circulation: novel techniques and applications.

PURPOSE OF REVIEW: Venous pressure is an often-unrecognized cause of patient morbidity. However, bedside assessment of PV is challenging. We review the clinical significance of venous pressure measurement, existing techniques, and introduce the Venous Excess Ultrasound (VExUS) Score as a novel approach using doppler ultrasound to assess venous pressure. RECENT FINDINGS: Studies show clear associations between elevated venous pressure and adverse outcomes in critically ill patients. Current venous pressure measurement techniques include physical examination, right heart catheterization (RHC), two-dimensional ultrasound, and a variety of labor-intensive research-focused physiological maneuvers. Each of these techniques have specific shortcomings, limiting their clinical utility. To address these gaps, Beaubien-Souligny et al. introduced the VExUS Score, a novel doppler ultrasound-based method that integrates IVC diameter with doppler measurements of the hepatic, portal, and renal veins to generate a venous congestion assesment. Studies show strong correlations between VExUS score and RHC measurements, and well as an association between VExUS score and improvement in cardiorenal acute kidney injury, diuretic response, and fluid status shifts. However, studies in noncardiac populations have been small, heterogenous, and inconclusive. SUMMARY: Early studies evaluating the use of doppler ultrasound to assess venous congestion show promise, but further research is needed in diverse patient populations and clinical settings.

Otolaryngology-head and neck surgery resident and medical school characteristics: Current paradigm amidst changing application criteria.

PURPOSE: To determine the characteristics of current US Otolaryngology-Head and Neck Surgery (Oto-HNS) residents and their medical school. METHODS: Data were manually collected between Dec 2022 and Jan 2023 for 1649 residents attending 163 US-based ACGME accredited Oto-HNS residency programs, reflecting the 2018-2022 cohort. All data were collected from publicly available sources including residency and medical school program websites, web of science, and professional networking sites (ex: LinkedIn, Doximity). Data were analyzed to determine the "feeder" schools which contributed the greatest number and percent of residents. Using univariable linear regression models, we characterized factors which were associated with feeder school status. RESULTS: Of 1649 residents analyzed, 364 (22 %) matched to their home program and 918 (56 %) stayed in the region of their medical school. The median [IQR] number of published papers and abstracts was 5 [3, 9] with an h-index of 2 [1,4]. Factors associated with producing a greater percent of Oto-HNS residents include presence of an interest group, presence of a home program, USNWR research rank of the medical school, Doximity reputation rank of the home residency program, average pre-residency h-index of the school's graduates, and total NIH research funding (each p < 0.001). CONCLUSIONS: In the changing landscape of residency applications after the USMLE Step 1 exam's transition in January 2022 to pass/fail scoring, it is important to objectively characterize current Oto-HNS residents. Findings from this study will inform prospective residents and residency programs seeking to improve access to Oto-HNS. Future small-scale studies may help further identify driving factors within medical school curricula.

The Increasing Problem of Syphilis Manifesting as Head and Neck Cancer: A Case Series.

Syphilis is an infectious disease caused by the spirochete Treponema pallidum. Rates have been rising in the US and globally. Known as the "Great Imitator," syphilis can involve head and neck subsites, and often can masquerade as possible carcinoma of the head and neck. Here, we present three distinct cases of syphilis presenting as suspected head and neck malignancy involving the oropharynx, larynx and oral cavity. All cases were diagnosed on surgical pathologic examination of diseased tissues and treated. It is important for practicing otolaryngologists to understand head and neck manifestations of syphilis to facilitate proper diagnosis and treatment. Laryngoscope, 134:236-239, 2024.

Influence of the COVID-19 Pandemic on Health-Care Career Interests Among High School Students.

PURPOSE: This study investigates the influence of the COVID-19 pandemic on high school students' interest in health-care careers. METHODS: A voluntary web-based survey, approved by the Medical College of Wisconsin's Institutional Review Board, was administered across eight high schools in Milwaukee and its suburbs in Wisconsin. The survey collected students' demographic details, opinions on the health-care system's pandemic response, and their interest in health-care careers before and after the pandemic. RESULTS: Out of 2,949 respondents, 29.9% were already contemplating a health-care career before the pandemic, with 27.7% indicating increased interest thereafter. Students not previously interested in health-care careers registered an 11.5% increase in interest due to the pandemic. Notably, the pandemic significantly boosted health-care career interest among females and freshmen. DISCUSSION: The COVID-19 pandemic has distinctly influenced high school students' interest in health-care careers, notably among females and freshmen. This finding has implications for addressing projected health-care professional shortages.

Christmas article: Minimally invasive (Christmas) heart surgery.

Introduction The woven Christmas heart is a cherished tradition and an iconic symbol of Danish Christmas. The common approach is to weave Christmas hearts by hand, however, as surgery is moving towards a minimally invasive approach, we wished to assess whether Christmas hearts could be weaved in a minimally invasive approach. Methods A single-blinded randomized crossover trial. All participants had to weave three Christmas hearts; one by hand, one laparoscopic, and one by a robotic approach within eight minutes. The hearts were assessed visually by a Danish Christmas expert and designer. Two trained surgeons received additional attempts, with no time limit, at weaving Christmas hearts by a laparoscopic and by a robotic approach. Results The study showed that it was possible to weave Christmas hearts by a minimally invasive approach. However, Christmas hearts woven by hand were significantly more elegant (p less-than 0.001 for both), as well as significantly faster to weave (p less-than 0.001 for both) than hearts woven by a laparoscopic or robotic approach. Furthermore, experienced surgeons tended to weave more elegant Christmas hearts than inexperienced surgeons (p = 0.051). Conclusion Minimally invasive approaches to surgery can be used to weave Christmas hearts, however, these approaches did not lead to more elegant or faster weaving of the Christmas hearts. Furthermore, surgical experience and experience with minimally invasive surgical approaches led to more elegant Christmas hearts. Funding none. Trial registration none.

Navigating Informed Consent and Patient Safety in Surgery: Lessons for Medical Students and Junior Trainees.

AbstractIn the operating room, patient safety is of paramount importance. Medical students and junior trainees, despite their primary role as students, may play active roles in assessing patient safety and reporting suspected errors. Active consent is one layer of patient safety that is continuously assessed by several team members. This article examines an instance where patient consent may have been violated. Through the lens of trainee and senior perspectives, we discuss the ethical principles at stake and provide recommendations for medical student and junior trainee involvement in patient care when an error is suspected.

Transcriptomic profiling of tissue environments critical for post-embryonic patterning and morphogenesis of zebrafish skin.

Pigment patterns and skin appendages are prominent features of vertebrate skin. In zebrafish, regularly patterned pigment stripes and an array of calcified scales form simultaneously in the skin during post-embryonic development. Understanding the mechanisms that regulate stripe patterning and scale morphogenesis may lead to the discovery of fundamental mechanisms that govern the development of animal form. To learn about cell types and signaling interactions that govern skin patterning and morphogenesis, we generated and analyzed single-cell transcriptomes of skin from wild-type fish as well as fish having genetic or transgenically induced defects in squamation or pigmentation. These data reveal a previously undescribed population of epidermal cells that express transcripts encoding enamel matrix proteins, suggest hormonal control of epithelial-mesenchymal signaling, clarify the signaling network that governs scale papillae development, and identify a critical role for the hypodermis in supporting pigment cell development. Additionally, these comprehensive single-cell transcriptomic data representing skin phenotypes of biomedical relevance should provide a useful resource for accelerating the discovery of mechanisms that govern skin development and homeostasis.

Disparities in Pediatric Orthopedic Surgery Care During the COVID-19 Pandemic Pre-vaccine and Post-Vaccine Availability.

BACKGROUND: The COVID-19 pandemic has led to significant disruptions in medical care, resulting in an estimated 40% of US adults avoiding care. However, the return to baseline health care utilization following COVID-19 restrictions within the pediatric orthopedic population remains unexplored. We sought to analyze the visit volume and demographics of pediatric orthopedic patients at 3 timepoints: prepandemic (2019), pandemic (2020), and pandemic post-vaccine availability (2021), to determine the impact of COVID-19 restrictions on our single-center, multisite institution. METHODS: We performed a retrospective cohort study of 6318 patients seeking treatment at our institution from May through August in 2019, 2020, and 2021. Patient age, sex, address, encounter date, and ICD-10 codes were obtained. Diagnoses were classified into fractures and dislocations, non-fracture-related trauma, sports, elective, and other categories. Geospatial analysis comparing incidence and geospatial distribution of diagnoses across the time periods was performed and compared with the Centers for Disease Control (CDC) social vulnerability index (SVI). RESULTS: The total number of pediatric orthopedic visits decreased by 22.2% during the pandemic ( P <0.001) and remained 11.6% lower post-vaccine availability compared with prepandemic numbers ( P <0.001). There was no significant difference in age ( P =0.097) or sex ( P =0.248) of the patients across all 3 timepoints; however, patients seen during the pandemic were more often White race (67.7% vs. 59.3%, P <0.001). Post-vaccine availability, trauma visits increased by 18.2% ( P <0.001) and total fractures remained 13.4% lower than prepandemic volume ( P <0.001). Sports volume decreased during the pandemic but returned to prepandemic volume in the post-vaccine availability period ( P =0.298). Elective visits did not recover to prepandemic volume and remained 13.0% lower compared with baseline ( P <0.001). Geospatial analysis of patient distribution illustrated neighborhood trends in access to care during the COVID-19 pandemic, with fewer patients from high SVI and low socioeconomic status neighborhoods seeking fracture care during the pandemic than prepandemic. Post-vaccine availability, fracture population distribution resembled prepandemic levels, suggesting a return to baseline health care utilization. CONCLUSION: Pediatric orthopedic surgery visit volume broadly decreased during the COVID-19 pandemic and did not return to prepandemic levels. All categories increased in the post-vaccine availability time point except elective visits. Geospatial analysis revealed that neighborhoods with a high social vulnerability index (SVI) were associated with decreased fracture visits during the pandemic, whereas low SVI neighborhoods did not experience as much of a decline. Future research is needed to study these neighborhood trends and more completely characterize factors preventing equitable access to care in the pediatric orthopedic population. LEVEL OF EVIDENCE: Retrospective Study, Level III.

U.S. West Coast droughts and heat waves exacerbate pollution inequality and can evade emission control policies.

Droughts reduce hydropower production and heatwaves increase electricity demand, forcing power system operators to rely more on fossil fuel power plants. However, less is known about how droughts and heat waves impact the county level distribution of health damages from power plant emissions. Using California as a case study, we simulate emissions from power plants under a 500-year synthetic weather ensemble. We find that human health damages are highest in hot, dry years. Counties with a majority of people of color and counties with high pollution burden (which are somewhat overlapping) are disproportionately impacted by increased emissions from power plants during droughts and heat waves. Taxing power plant operations based on each plant's contribution to health damages significantly reduces average exposure. However, emissions taxes do not reduce air pollution damages on the worst polluting days, because supply scarcity (caused by severe heat waves) forces system operators to use every power plant available to avoid causing a blackout.

Efficient Synthesis of High-Performance Anion Exchange Membranes by Applying Clickable Tetrakis(dialkylamino)phosphonium Cations.

Tetrakis(dialkylamino)phosphonium (TKDAAP) compounds exhibit extraordinary base resistance, a prerequisite feature for high-performance anion exchange membranes (AEMs). It is, however, challenging to synthesize a TKDAAP compound with reactive functionality that can be used to link the cation to a polymer backbone. In this study, two TKDAAP compounds with alkyne functionality were synthesized and incorporated into an azide-modified SBS triblock copolymer backbone via Cu(I)-catalyzed alkyne-azide cycloaddition (CuAAC) "click" chemistry. The properties of the resulting AEMs were characterized. It was found that (1) the triazole linker between the cation and the polymer backbone was stable under alkaline conditions; (2) varying the substituents of TKDAAP compounds could dramatically alter the stability; and (3) increasing the hydrophilicity of the AEM was an efficient way to enhance its ionic conductivity. Using clickable TKDAAP compounds makes it easy to combine various cations into polymer backbones with adjustable cation content, thus potentially leading to an efficient way to screen a wide variety of polyelectrolyte structures to identify the most promising candidates for high-performance AEMs.

Mesenteric traction syndrome - Incidence, impact, and treatment: A systematic scoping review of the literature.

BACKGROUND: Mesenteric traction syndrome (MTS) is commonly seen during major abdominal surgery and is characterised by facial flushing, hypotension, and tachycardia 15 min into surgery. MTS also impacts the postoperative course, as severe MTS has been associated with increased postoperative morbidity. However, despite MTS being common and severe MTS causing increased postoperative morbidity, the gaps in the literature are not clearly defined. We aimed to examine the diagnostic criteria, incidence, intraoperative and postoperative impact, and potential preventative measures of MTS while highlighting potential gaps in the literature. METHODS: We followed the Prisma guidelines and performed a systematic literature search. We included only human studies examining MTS. All hits were screened for title and abstract, followed by a full-text review by at least two authors for determining eligibility for inclusion. Data were extracted and risk of bias was assessed by two independent reviewers. RESULTS: A total of 37 studies, comprising 1102 patients were included in the review. The combined incidence of MTS during open abdominal surgery was found to be 76%, with 35% developing severe MTS. It was found that the development of MTS was associated with marked haemodynamic changes. It was also found that several different subjective diagnostic criteria exist and that severe MTS was associated with increased postoperative morbidity. Furthermore, several preventative measures for protecting against MTS have been examined, but only on the incidence of MTS and not on the postoperative course. CONCLUSION: MTS occurs in 76% of patients undergoing major abdominal surgery and is associated with deleterious haemodynamic effects, which are more pronounced in patients developing severe MTS. Severe MTS is also associated with a worse postoperative outcome. However, gaps are still present in the current literature on MTS.

A Quality Improvement Approach to Modification of a Point-of-Care Ultrasound Curriculum.

Background: There is increasing emphasis on resident involvement in quality improvement (QI) efforts, yet resident engagement in QI has remained low for many reasons. Although QI methods are classically applied to clinical processes, there are many opportunities to incorporate QI principles into curricular design and implementation. Objective: Demonstrate the utility of QI methods when applied to curricular design and the implementation of a novel point-of-care ultrasound portfolio development and quality assurance program at a large internal medicine residency program. Methods: We applied foundational QI methods, including process mapping, plan-do-study-act (PDSA) cycles, time-trap identification, run-chart analysis, and qualitative interviews throughout the curricular design and implementation phases to rapidly identify areas for improvement and perform timely tests of change. Results: Fifty-one interns participated in the curriculum, submitting 731 images in the first trimester. Process mapping and submission review revealed that 29% of images were saved to the incorrect digital archive. Resident-reviewer interpretation concordance was present in 80.7% of submissions. In 95.2% of completed quality assurance cards, the same information was provided in the commentary feedback and the evaluator's checklists, representing a time trap. Interventions included restricting access to image archives and removing redundant fields from quality assurance cards. The time to feedback fell from 69.5 to 6.5 days, demonstrating nonrandom variation via run-chart analysis. Conclusion: This pilot study demonstrates the successful application of QI methods to a novel point-of-care ultrasound curriculum. The systematic use of these methodologies in curricular design and implementation allows expeditious curricular improvement. Emphasizing the relevance of QI methods to subject matter beyond clinical processes may increase resident engagement in QI efforts.

The pipeline starts in medical school: characterizing clinician-educator training programs for U.S. medical students.

In the past forty years, clinician-educators have become indispensable to academic medicine. Numerous clinician-educator-training programs exist within graduate medical education (GME) as clinician-educator tracks (CETs). However, there is a call for the clinician-educator pipeline to begin earlier. This work aims to identify and characterize clinician-educator track-like programs (CETLs) available in undergraduate medical education (UME). We developed an algorithm of 20 individual keyword queries to search the website of each U.S. allopathic medical school for CETLs. We performed the web search between March to April 2021 and repeated the search between July and September 2021. The search identified CETLs for 79 (51%) of the 155 U.S. allopathic medical schools. The identified CETLs commonly address the clinician-educator competency of educational theory (86%, 68/79), are formally organized as concentrations or analogous structures (52%, 41/79), and span all four years of medical school (37%, 29/79). The prevalence of CETLs varies with geography and medical school ranking. We provide an overview of the current state of CETLs as assessed from institutional websites. To create a future with a sustainable output of skilled clinician-educators, UME must continue to increase the number and quality of CETLs.

A semaphorin-plexin-Rasal1 signaling pathway inhibits gastrin expression and protects against peptic ulcers.

Peptic ulcer disease is a frequent clinical problem with potentially serious complications such as bleeding or perforation. A decisive factor in the pathogenesis of peptic ulcers is gastric acid, the secretion of which is controlled by the hormone gastrin released from gastric G cells. However, the molecular mechanisms regulating gastrin plasma concentrations are poorly understood. Here, we identified a semaphorin-plexin signaling pathway that operates in gastric G cells to inhibit gastrin expression on a transcriptional level, thereby limiting food-stimulated gastrin release and gastric acid secretion. Using a systematic siRNA screening approach combined with biochemical, cell biology, and in vivo mouse experiments, we found that the RasGAP protein Rasal1 is a central mediator of plexin signal transduction, which suppresses gastrin expression through inactivation of the small GTPase R-Ras. Moreover, we show that Rasal1 is pathophysiologically relevant for the pathogenesis of peptic ulcers induced by nonsteroidal anti-inflammatory drugs (NSAIDs), a main risk factor of peptic ulcers in humans. Last, we show that application of recombinant semaphorin 4D alleviates peptic ulcer disease in mice in vivo, demonstrating that this signaling pathway can be harnessed pharmacologically. This study unravels a mode of G cell regulation that is functionally important in gastric homeostasis and disease.

HIV Disease Dynamics and Markers of Inflammation and CNS Injury During Primary HIV Infection and Their Relationship to Cognitive Performance.

INTRODUCTION: Early systemic and central nervous system viral replication and inflammation may affect brain integrity in people with HIV, leading to chronic cognitive symptoms not fully reversed by antiretroviral therapy (ART). This study examined associations between cognitive performance and markers of CNS injury associated with acute HIV infection and ART. METHODS: HIV-infected MSM and transgender women (average age: 27 years and education: 13 years) enrolled within 100 days from the estimated date of detectable infection (EDDI). A cognitive performance (NP) protocol was administered at enrollment (before ART initiation) and every 24 weeks until week 192. An overall index of cognitive performance (NPZ) was created using local normative data. Blood (n = 87) and cerebrospinal fluid (CSF; n = 29) biomarkers of inflammation and neuronal injury were examined before ART initiation. Regression analyses assessed relationships between time since EDDI, pre-ART biomarkers, and NPZ. RESULTS: Adjusting for multiple comparisons, shorter time since EDDI was associated with higher pre-ART VL and multiple biomarkers in plasma and CSF. NPZ scores were within the normative range at baseline (NPZ = 0.52) and at each follow-up visit, with a modest increase through week 192. Plasma or CSF biomarkers were not correlated with NP scores at baseline or after ART. CONCLUSIONS: Biomarkers of CNS inflammation, immune activation, and neuronal injury peak early and then decline during acute HIV infection, confirming and extending results of other studies. Neither plasma nor CSF biomarkers during acute infection corresponded to NP scores before or after sustained ART in this cohort with few psychosocial risk factors for cognitive impairment.

Student-Designed Cross-Sectional Pandemic Knowledge Survey of 8th-12th Grade Students, Milwaukee, WI, April 2020.

Background: The novel coronavirus and its effect on our society are unprecedented. Given the recent pandemic, numerous measures have been taken to protect our communities. We sought to understand our school community's knowledge and the measures that were taken by our school for our safety. Objective: Our objective was to describe the overall understanding and attitudes of 8-12th grade students from a single institution during the initial phase of the Wisconsin's Governor's stay-at-home order. Methods: A voluntary web-based survey was communicated to 8-12th grade students through their online school portal. Data were collected and analyzed using SurveyMonkey. Results: There was a 20.2% response rate. Answers regarding the coronavirus, spread, and response to the coronavirus pandemic showed a high level of understanding of the virus and the actions necessary to prevent its spread. Conclusion: Eight-twelfth grade students have a high level of understanding of the virus, its effects, and the safety measures implemented to protect society.

Endoscopic treatment of primary aorto-enteric fistulas: A case report and review of literature.

BACKGROUND: Primary aorto-enteric fistula (PAEF) is a rare condition, traditionally treated in the acute, bleeding phase with open surgery or endovascular repair. However, these approaches have high morbidity and mortality, indicating a need for new methods. With advances in endoscopic techniques and equipment, haemoclipping of fistulas has now become feasible. Therefore, we present a systematic review of the English literature and a rare case of a PAEF successfully treated by endoscopic haemoclipping. CASE SUMMARY: A 74-year-old man with an abdominal aortic aneurysm presented with symptoms of haemorrhagic shock and bloody stools. An oesophago-gastro-duodenoscopy was performed with haemoclipping of a suspected PAEF in the third part of the duodenum. Afterward, a computed tomography-angiography showed a contrast filled protrusion from the abdominal aortic aneurysm. Based on the clinical presentation and the combined endoscopic and radiographic findings, we argue that this is a case of a PAEF. CONCLUSION: Endoscopic therapy appears capable of achieving haemodynamic stabilisation in patients with bleeding PAEF, serving as a bridge to final therapy.