Implementing a 3 year, longitudinal point of care ultrasound curriculum in an internal medicine residency program.

PURPOSE: Point-of-care ultrasound (POCUS) is highly utilized in the critical care setting. There is also growing evidence supporting use of POCUS by internal medicine (IM) physicians as an extension of traditional physical diagnostic skills. As part of the newly formed curriculum at our residency program, we performed pre and post curriculum assessment of the residents' ability to acquire focused cardiac, lung, pleural, abdominal and vascular images. METHODS: The POCUS instruction was delivered as a combination of pre-workshop self-study learning materials (monthly textbook chapters, online modules etc.), with short didactic sessions, and hands-on-scanning of healthy, male volunteers at 10-week intervals. RESULTS: A total of 62 residents (23 Post-Graduate Year 1 (PGY), 24 PGY2, 15 PGY3) participated in the year-long curriculum. When pretest and post test data were analyzed at the end of the curriculum, we calculated the odds ratio for acquiring the correct image (score of 1) vs partial/incorrect acquisition (scores of 2 and 3). Significant differences were found in acquisition of most views including para-sternal short (OR 7.7, 95% CI 2.86-20.74, p < 0.001), Inferior vena cava (IVC) (OR 5.05, 95% CI 1.91-13.35, p = 0.001) and bladder (OR 5.06, 95% CI 1.76-14.55, p = 0.003). Non-significant differences were found in acquisition of apical 4 chamber, pl (A-Line) and internal jugular vein (IJV). CONCLUSION: We found that the implementation of a longitudinal POCUS curriculum resulted in significant improvement in image acquisition for many common bedside ultrasound views. Future directions include advancing our bedside echocardiography curriculum for upper-level residents to include quantitative left ventricular and right ventricular function analysis, and including more case based pathologic image review.

Endotipsitis: a rare case of endovascular infection with ESBL Klebsiella pneumoniae.

Endotipsitis is a vegetative endovascular infection of a transjugular intrahepatic portosystemic shunt (TIPS). There is currently no uniformly accepted diagnostic criterion, and most cases are diagnosed by clinical diagnosis of recurrent bacteraemia in patients with TIPS and no identifiable source after appropriate investigation. We present a case of 62-year-old man in whom endotipsitis was suspected clinically after emergent TIPS placement complicated by TIPS thrombosis, need for TIPS revision and recurrent bacteraemia. The diagnosis was confirmed using an Indium-111-labelled leucocyte scan (tagged white blood cell scan). This case highlights the potential risks of endotipsitis with TIPS procedures and provides insight into the utilisation of an old diagnostic tool in a new diagnostic role.

MicroRNAs in CSF as prodromal biomarkers for Huntington disease in the PREDICT-HD study.

OBJECTIVE: To investigate the feasibility of microRNA (miRNA) levels in CSF as biomarkers for prodromal Huntington disease (HD). METHODS: miRNA levels were measured in CSF from 60 PREDICT-HD study participants using the HTG protocol. Using a CAG-Age Product score, 30 prodromal HD participants were selected based on estimated probability of imminent clinical diagnosis of HD (i.e., low, medium, high; n = 10/group). For comparison, participants already diagnosed (n = 15) and healthy controls (n = 15) were also selected. RESULTS: A total of 2,081 miRNAs were detected and 6 were significantly increased in the prodromal HD gene expansion carriers vs controls at false discovery rate q < 0.05 (miR-520f-3p, miR-135b-3p, miR-4317, miR-3928-5p, miR-8082, miR-140-5p). Evaluating the miRNA levels in each of the HD risk categories, all 6 revealed a pattern of increasing abundance from control to low risk, and from low risk to medium risk, which then leveled off from the medium to high risk and HD diagnosed groups. CONCLUSIONS: This study reports miRNAs as CSF biomarkers of prodromal and diagnosed HD. Importantly, miRNAs were detected in the prodromal HD groups furthest from diagnosis where treatments are likely to be most consequential and meaningful. The identification of potential biomarkers in the disease prodrome may prove useful in evaluating treatments that may postpone disease onset. CLINICALTRIALSGOV IDENTIFIER: NCT00051324.