Ocular manifestations of severe familial hypercholesterolemia.

Background: To study ocular manifestations of patients with severe familial hypercholesterolemia (FH). Methods: In this population-based case-control study, patients suffering from severe familial hypercholesterolemia from the Lebanese Familial Hypercholesterolemia Registry, along with age and gender-matched healthy controls were recruited. All participants underwent a comprehensive eye examination, and patients underwent fluorescein angiography as well. Logistic regression models were used to identify any association between patients with severe familial hypercholesterolemia and abnormal eye findings, while adjusting for hypertension and pack-year smoking. The main outcome measure of this study was the development of ocular vascular abnormalities. Results: 28 patients and 28 controls were recruited. Patients with severe familial hypercholesterolemia had significantly greater odds of developing corneal arcus and xanthelasmas than the control group (p < 0.001). Retinal vascular abnormalities (plaques) were exclusively and more significantly present in patients with familial hypercholesterolemia (18 %). Similarly, retinal arteriosclerosis was exclusively and significantly more prevalent in the familial hypercholesterolemia group (p < 0.001, adjusted odds ratio 6.8). Stratification by LDL levels and genotypes did not show any significant change in the prevalence of any ocular finding. Conclusion: In addition to the well-established increase in incidence of corneal arcus and xanthelasmas, severe familial hypercholesterolemia patients have more prevalent retinal vascular abnormalities that include vascular plaques and arteriosclerosis.

Teaching and Assessing Bedside Procedures: A Standardized Cross-Disciplinary Framework for Graduate Medical Education.

ABSTRACT: Performing bedside procedures requires knowledge, reasoning, physical adeptness, and self-confidence; however, no consensus on a specific, comprehensive strategy for bedside procedure training and implementation is available. Bedside procedure training and credentialing processes across large institutions may vary among departments and specialties, leading to variable standards, creating an environment that lacks consistent accountability, and making quality improvement difficult. In this Scholarly Perspective, the authors describe a standardized bedside procedure training and certification process for graduate medical education with a common, institution-wide educational framework for teaching and assessing the following 7 important bedside procedures: paracentesis; thoracentesis; central venous catheterization; arterial catheterization; bladder catheterization or Foley catheterization; lumbar puncture; and nasogastric, orogastric, and nasoenteric tube placement. The proposed framework is a 4-stage process that includes 1 preparatory learning stage with simulation practice for knowledge acquisition and 3 clinical stages to guide learners from low-risk to high-risk practice and from high to low supervision. The pilot rollout took place at Henry Ford Hospital from December 2020 to July 2021 for 165 residents in the emergency medicine and/or internal medicine residency programs. The program was fully implemented institution-wide in July 2021. Assessment strategies encompass critical action checklists to confirm procedural understanding and a global rating scale to measure performance quality. A major aim of the bedside procedure training and certification was to standardize assessments so that physician trainers from multiple specialties could train, assess, and supervise any participating trainee, regardless of discipline. The authors list considerations revealed from the pilot rollout regarding electronic tracking systems and several benefits and implementation challenges to establishing institution-wide standards. The proposed framework was assembled by a multidisciplinary physician task force and will assist other institutions in adopting best approaches for training physicians in performing these critically important and difficult-to-perform procedures.

Acute coronary syndrome prediction in emergency care: A machine learning approach.

BACKGROUND AND OBJECTIVE: Clinical concern for acute coronary syndrome (ACS) is one of emergency medicine's most common patient encounters. This study aims to develop an ensemble learning-driven framework as a diagnostic support tool to prevent misdiagnosis. METHODS: We obtained extensive clinical electronic health data on patient encounters with clinical concerns for ACS from a large urban emergency department (ED) between January 2017 and August 2020. We applied an analytical framework equipped with many well-developed algorithms to improve the data quality by addressing missing values, dimensionality reduction, and data imbalance. We trained ensemble learning algorithms to classify patients with ACS or non-ACS etiologies of their symptoms. We used performance evaluation metrics such as accuracy, sensitivity, precision, F1-score, and the area under the receiver operating characteristic (AUROC) to measure the model's performance. RESULTS: The analysis included 31,228 patients, of whom 563 (1.8%) had ACS and 30,665 (98.2%) had alternative diagnoses. Eleven features, including systolic blood pressure, brain natriuretic peptide, chronic heart disease, coronary artery disease, creatinine, glucose, heart attack, heart rate, nephrotic syndrome, red cell distribution width, and troponin level, are reported as significantly contributing risk factors. The proposed framework successfully classifies these cohorts with sensitivity and AUROC as high as 86.3% and 93.3%. Our proposed model's accuracy, precision, specificity, Matthew's correlation coefficient, and F1-score were 85.7%, 86.3%, 93%, 80%, and 86.3%, respectively. CONCLUSION: Our proposed framework can identify early patients with ACS through further refinement and validation.

Situs Inversus: Inferior-Lateral ST-Elevation Myocardial Infarction on Right-Sided Electrocardiogram.

Dextrocardia is a rare anatomical anomaly in which the heart is located in the patient's right hemithorax with its apex directed to the right. Although it usually does not pose any serious health risks, patients with undiagnosed dextrocardia present a diagnostic challenge especially in those presenting with chest pain. Traditional left-sided electrocardiograms (ECG) inadequately capture the electrical activity of a heart positioned in the right hemithorax, which if unnoticed could delay or even miss an acute coronary syndrome diagnosis. Here, we present a case of a patient with dextrocardia presenting with chest pain and diagnosed with ST-elevation myocardial infarction using a right-sided ECG.

Back pain: A puzzle in children.

Back pain in children is underdiagnosed and increases incidence in adolescence. A systematic approach can diagnose the most common causes: trauma, structural deformities, inflammatory diseases, infection and malignancy.