Pulmonary-Renal Syndrome from Levamisole-Adulterated Cocaine-Induced Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis: A Systematic Review.

Levamisole is an anti-helminthic drug with immunomodulatory properties that is added to cocaine to increase its potency and weight. Levamisole-adulterated cocaine (LAC) may cause an antineutrophil cytoplasmic antibody (ANCA)-associated systemic small vessel vasculitis (AAV). We aimed to characterize the phenotype of persons developing pulmonary-renal syndrome (PRS) in LAC-induced AAV and summarize its treatment and outcomes. Pubmed and Web of Science were searched (until September 2022). Reports that described co-existing diffuse alveolar hemorrhage and glomerulonephritis in an adult (age ≥ 18) with confirmed or suspected LAC exposure were included. Reports, demographics, clinical and serologic features, treatment and outcome characteristics were extracted. Of the 280 records identified, eight met the inclusion criteria, including eight unique cases. Persons were aged 22-58 years, and 50% were women. Cutaneous involvement occurred in only half of the cases. Other associated vasculitis findings and serologies were heterogeneous. All patients received immunosuppression with steroids, with cyclophosphamide and rituximab commonly added. We concluded that PRS could occur from LAC-induced AAV. Distinguishing LAC-induced AAV from primary AAV is challenging as clinical and serologic presentations overlap. Asking about cocaine use is requisite in persons presenting with PRS to guide diagnosis and appropriately counsel on cocaine cessation in conjunction with immunosuppression as treatment.

The Need for More Mentorship in Medical School.

Introduction Mentorship, a supportive relationship that actively provides knowledge and insight, has many benefits. Although not extensively studied, medical students pursuing various specialties have diverse experiences with mentorship. Objective To understand how mentorship impacts medical student decisions involving rotation choices, residency programs, field of practice, interest in research, and career trajectory. Methods We hypothesized that effective mentor-mentee relationships would strongly impact medical students' decisions. Distributed to fourth-year osteopathic medical students at a single medical school, this study used a survey design to assess mentorship's impact on their aforementioned decisions. Results Sixty-one students responded to this survey. Fifty-nine percent of respondents said they did not receive enough mentorship in medical school while 63.9% of respondents said their quality of mentorship was good/very good. Most survey respondents strongly agreed/agreed that the amount and quality of mentorship impacted their decisions involving rotation choices, residency programs, field of practice, and career trajectory. Qualitative data analysis led to the emergence of three themes: students pursuing primary care had positive mentorship experiences as compared to students pursuing non-primary care careers, female students stated they did not receive enough mentorship, and a majority of students cited the lack of formal mentorship as an area of improvement. Conclusions Our study demonstrates the profound impact mentorship has on a medical student's career. Respondents believed their mentorship experiences strongly impacted their decisions involving rotation choices, residency programs, field of practice, and career trajectory. Participants also believed availability in the amount and quality of mentorship could be improved. The perceived lack in the amount and quality of mentorship may have negative implications on medical students' career prospects.

A "U-shaped" Curve: Appreciating How Primary Care Residency Intention Relates to the Cost of Board Preparation and Examination.

INTRODUCTION: The shortage of primary care physicians in the United States has warranted an investigation into how medical education debt and other factors influence medical students' interests in primary care (PC) residencies. However, sparse research has studied how the cost of board preparation and examination relates to career choice. The objective of this study was to determine if there is an association between the cost of preparing and sitting for board examinations and the intention to enter a PC residency for osteopathic medical students. METHODS: We postulated that students who incurred higher financial costs from preparing and sitting for board examinations would be more likely to be interested in non-primary care (NPC) residencies. Using a non-experimental survey design, this study asked respondents to evaluate the following: "I plan to enter a Primary Care Residency (Family Medicine OR General Internal Medicine OR Pediatrics)" using a Likert scale. Respondents were also asked to select which board examination(s) and pertinent resource(s) they had purchased. Total costs were calculated per student. RESULTS: A total of 25,852 osteopathic medical students received the survey, of which 1,280 students responded to and completed it, yielding a 4.95% response rate. The distribution of respondents' intentions to pursue a primary care residency and costs spent yielded a "U" shaped curve. Respondents who Strongly Agreed and Strongly Disagreed to the statement "I plan to enter a Primary Care Residency" spent $5,744 and $5,070 on board-preparation and examination, respectively. No statistically significant differences were found between the cost of preparing and sitting for board examinations and the intention to enter primary care residencies when individuals were grouped by year in school and gender. CONCLUSIONS: Because competitive NPC specialties have relatively higher salaries, we suspected that students who intended to pursue these specialties would have had higher financial costs from board examination and preparation compared to students who intended to pursue PC residencies such as family medicine. Our findings further illustrate these specific educational costs do not correlate with students' stated intentions to enter primary care residencies. As efforts continue to determine a solution for the primary care physician shortage, it becomes clearer that the focus must also encompass non-financial influences that shape career choice.

Multiple Evanescent White Dot Syndrome Presenting in Possibly Contracted Hand-Foot-and-Mouth Disease: A Rare Presentation.

Multiple evanescent white dot syndrome (MEWDS), an inflammatory retinal condition seen predominantly in young adult patients, is characterized by unilateral vision loss with variable scotomas. The etiology of MEWDS is currently elusive and the formal mechanism is unknown. However, it must be differentiated from other white dot syndromes (WDS). Fundus fluorescein angiography in MEWDS exhibits a "wreath-like" arrangement of hyperfluorescent lesions predominantly located in the outer retina. Herein we present a case of a 32-year-old Southeast Asian female who presented to the emergency department with peripheral blindness and central scotomas. The patient's daughter was diagnosed with hand-foot-and-mouth disease seven days earlier, which often presents as an extremely debilitating condition. Below, we elaborate on the etiology, pathogenesis, and diagnostic methods to elucidate the multifactorial causes of MEWDS and aid clinicians in diagnosis and treatment. Although associated with certain viral illnesses, to the best of our knowledge, there have been no reported cases of MEWDS in conjunction with hand-foot-and-mouth disease.

The Cost of Board Examination and Preparation: An Overlooked Factor in Medical Student Debt.

Objective Board examinations in undergraduate medical education are imperative for competency assessment and a standard licensure process. While the cost of attendance and mean indebtedness of medical students have been quantified, the financial burden experienced by medical students from board preparation and examination has never been quantified. Materials and methods A total of 290 fourth-year osteopathic medical students from 38 osteopathic medical schools completed an anonymous survey that asked them to select the resources they had purchased for board preparation. Along with demographic information, respondents were asked which board examinations they had taken during their medical school education. The price for each resource was located by going to the resource website and finding the "list price" of a brand-new copy/version of that resource. If a price was not found, a current Amazon.com "list price" was utilized. These prices best approximate the maximum a student would spend per resource. Response and statistical analysis such as analysis of variance, post hoc comparison (Scheffé and Bonferronis test), and chi-square tests were conducted using the Statistical Package for Social Sciences (SPSS) Statistics, version 25.0 (IBM SPSS Statistics, Armonk, NY). Results This study found that osteopathic medical students spent, on average, $7,499 (s.d.=$2,506) for board preparation and examination. This cost when isolated is $3,370 for the cost of taking board examinations and $4,129 for the cost of board preparation. Respondents from the West were found to spend most at $9,432, while students from the Northeast spent the least, $7.090. Additionally, non-traditional medical students, those who matriculated after the age of 30 were found to spend more than individuals who began when they were under the age of 25 or between the ages of 25-30. The two most commonly used resources for both Level 1/Step 1 and Level 2/Step 2 examinations were COMBANK and UWorld.  Conclusions/relevance This study is the first of its kind to quantify the mean cost of board preparation and examination in undergraduate medical education at $7,499. When considering the mean indebtedness of the osteopathic graduating class of 2017-2018, 2.94% of medical education debt can be attributed to the cost of board preparation and assessments. As competitiveness for graduate medical education increases, individuals will spend more money to ensure a competitive board exam performance, a key selection factor. Stakeholders in undergraduate medical education are encouraged to further understand the interplay between medical student debt and the cost of board examinations and preparation.

Telocinobufagin, a Novel Cardiotonic Steroid, Promotes Renal Fibrosis via Na⁺/K⁺-ATPase Profibrotic Signaling Pathways.

Cardiotonic steroids (CTS) are Na⁺/K⁺-ATPase (NKA) ligands that are elevated in volume-expanded states and associated with cardiac and renal dysfunction in both clinical and experimental settings. We test the hypothesis that the CTS telocinobufagin (TCB) promotes renal dysfunction in a process involving signaling through the NKA α-1 in the following studies. First, we infuse TCB (4 weeks at 0.1 µg/g/day) or a vehicle into mice expressing wild-type (WT) NKA α-1, as well as mice with a genetic reduction (~40%) of NKA α-1 (NKA α-1+/-). Continuous TCB infusion results in increased proteinuria and cystatin C in WT mice which are significantly attenuated in NKA α-1+/- mice (all p < 0.05), despite similar increases in blood pressure. In a series of in vitro experiments, 24-h treatment of HK2 renal proximal tubular cells with TCB results in significant dose-dependent increases in both Collagens 1 and 3 mRNA (2-fold increases at 10 nM, 5-fold increases at 100 nM, p < 0.05). Similar effects are seen in primary human renal mesangial cells. TCB treatment (100 nM) of SYF fibroblasts reconstituted with cSrc results in a 1.5-fold increase in Collagens 1 and 3 mRNA (p < 0.05), as well as increases in both Transforming Growth factor beta (TGFb, 1.5 fold, p < 0.05) and Connective Tissue Growth Factor (CTGF, 2 fold, p < 0.05), while these effects are absent in SYF cells without Src kinase. In a patient study of subjects with chronic kidney disease, TCB is elevated compared to healthy volunteers. These studies suggest that the pro-fibrotic effects of TCB in the kidney are mediated though the NKA-Src kinase signaling pathway and may have relevance to volume-overloaded conditions, such as chronic kidney disease where TCB is elevated.

Comparison of Pneumoperitoneum Stability Between a Valveless Trocar System and Conventional Insufflation: A Prospective Randomized Trial.

OBJECTIVE: To compare the variation in pneumoperitoneum and physiologic effects of patients undergoing laparoscopic renal surgery using the valveless trocar insufflation system (VI) vs a conventional insufflation system (CI). METHODS AND MATERIALS: We conducted a single-center, randomized controlled trial in patients undergoing renal surgery at 15 mm Hg insufflation using a VI system vs a CI system. The primary outcome measured was variation in insufflation pressure, and end-tidal CO2 at 10 and 25 minutes. RESULTS: Fifty-six patients (VI n = 28 or CI n = 28) met inclusion criteria and were randomized. There was significantly less variability in pressure readings, as measured by coefficient of variation, during VI compared to CI (7.8% vs 15.6%, P < .001). There was significantly less time spent within the range with pressure readings ≥18 mm Hg (median 0.2% vs 16.5%, P < .001) and ≤12 mm Hg (median 1.7% vs 5.6%, P = .011) during VI compared to CI. Additionally, there was significantly less time spent with pressure readings in the "unacceptable" range of ≥20 mm Hg (median 0% vs 0.08%, P < .001) and ≤10 mm Hg (median 0.09% vs 2.6%, P < .001) during the cases with VI compared to CI. End-tidal CO2 was significantly lower at 10 minutes (P = .036) after insufflation in the valveless trocar group compared to the conventional treatment group. There were no other significant differences in physiologic metrics. CONCLUSION: Compared with a CI, the VI provides a significantly more stable pneumoperitoneum during laparoscopic renal surgery and lower end-tidal CO2 at 10 minutes.

Technique for office-based, ultrasonography-guided percutaneous biopsy of renal cortical neoplasms using a novel transducer for facilitated ultrasound targeting.

OBJECTIVES: To help clarify which small renal cortical neoplasms (RCNs) require surgery by using office-based, ultrasonography-guided percutaneous renal biopsy. PATIENTS AND METHODS: Biopsies were performed using facilitated ultrasound targeting (FUT) technology, which incorporates a needle guide and onscreen beam-steered technology to permit highly precise needle deployment. Patient and tumour characteristics, procedure time, complications and biopsy efficacy were documented. Wong-Baker pain levels were obtained before, during and 1 h after the procedure. RESULTS: Seven patients underwent biopsy, six for RCNs and one for medical renal disease. The mean (range) patient age was 68.5 (54-79) years, and the mean (range) tumour diameter was 2.55 (2.0-2.9) cm. Mean pain levels before, during and 1 h after the procedure were 0, 1.6 and 0.5, respectively. There were no intra- or post-procedural complications. Biopsy results were diagnostic in five of the six RCN cases and in the single case of medical renal disease. CONCLUSIONS: Our preliminary experience shows that office-based percutaneous renal biopsy using a novel transducer for FUT is safe and effective. An international multicentre study is planned to confirm these preliminary results.

Development of a novel iPad-based laparoscopic trainer and comparison with a standard laparoscopic trainer for basic laparoscopic skills testing.

INTRODUCTION: We developed the iTrainer (iT) as a portable laparoscopic trainer, which incorporates the iPad tablet. We then compared the iT with a standard pelvic trainer (SPT) to assess surgical skills as well as its image quality, resolution, brightness, comfort, and overall performance. MATERIALS AND METHODS: We designed and constructed the iT to be compatible with the Apple iPad 3 and standard laparoscopic instruments. Participants were assigned to perform the thread-the-loops task on both trainers and were prospectively randomized to start on either the iT or the SPT. Each participant was allowed a 2-minute warm-up before the 2-minute testing period. We scored participants using the product of skill quality (0-4 scale) and quantity of loops threaded (0-10 scale). Participants then rated each trainer on image quality, resolution, brightness, comfort, and overall performance on a 5-point Likert scale. RESULTS: A total of 45 subjects including 10 undergraduates, 10 medical students, 10 general surgery and urology residents, and 15 experts (fellows and attending surgeons) participated in this study. There was no significant difference between thread-the-loops task scores completed on the iT when compared with the SPT for all groups tested (p > 0.05) with the exception of the medical student group, who performed better on the SPT (p < 0.05). On evaluation of each trainer, participants rated the iT as having superior image quality and resolution when compared with the SPT (p < 0.05) but rated the SPT higher in overall performance (p < 0.05). Brightness and comfort were rated similarly for both trainers. CONCLUSIONS: We have demonstrated face validity and criterion validity for the thread-the-loops task on the iT. The iT rated superior in image quality and resolution but inferior in overall performance compared with the SPT. The iT provides trainees a unique advantage over SPT as an additional resource to laparoscopic training as it is inexpensive, portable, and can be readily available for training.

Evaluation of the impact of three-dimensional vision on laparoscopic performance.

INTRODUCTION: Recent technological advancements have led to the introduction of new three-dimensional (3D) cameras in laparoscopic surgery. The 3D view has been touted as useful during robotic surgery, however, there has been limited investigation into the utility of 3D in laparoscopy. MATERIALS AND METHODS: We performed a prospective, randomized crossover trial comparing a 0° 3D camera with a conventional 0° two-dimensional (2D) camera using a high definition monitor (Karl Storz, Tuttlingen, Germany). All participants completed six standardized basic skills tasks. Quality testing scores were measured by the number of drops, grasping attempts, and precision of needle entry and exiting. Additionally, resolution, color distribution, depth of field and distortion were measured using optical test targets. RESULTS: In this pilot study, we evaluated 10 medical students, 7 residents, and 7 expert surgeons. There was a significant difference in the performance in all the six skill tasks, for the three levels of surgical expertise and training levels in 2D vs 3D except for the cut the line quality score and the peg transfer quality score. Adjusting for the training level, 3D camera image results were superior for the number of rings left (p=0.041), ring transfer quality score (p=0.046), thread the rings (no. of rings) (p=0.0004), and thread the rings quality score (p=0.0002). The 3D camera image was also superior for knot tying (quality score) (p=0.004), peg transfer (time in seconds) (p=0.047), peg transfer pegs left (p=0.012), and for peg transfer quality score (p=0.001). The 3D camera system showed significantly less distortion (p=0.0008), a higher depth of field (p=0.0004) compared with the 2D camera system. CONCLUSION: 3D laparoscopic camera equipment results in a significant improvement in depth perception, spatial location, and precision of surgical performance compared with the conventional 2D camera equipment. With this improved quality of vision, even expert laparoscopic surgeons may benefit from 3D imaging.

Comparison of optics and performance of a distal sensor high definition cystoscope, a distal sensor standard definition cystoscope, and a fiberoptic cystoscope.

OBJECTIVE: To evaluate performance characteristics and optics of a new generation high-definition distal sensor (HD-DS) flexible cystoscope, a standard-definition distal sensor (SD-DS) cystoscope, and a standard fiberoptic (FO) cystoscope. METHODS: Three new cystoscopes (HD-DS, SD-DS, and FO) were compared for active deflection, irrigation flow, and optical characteristics. Each cystoscope was evaluated with an empty working channel and with various accessories. Optical characteristics (resolution, grayscale imaging, color representation, depth of field, and image brightness) were measured using United States Air Force (USAF)/Edmund Optics test targets and illumination meter. We digitally recorded a porcine cystoscopy in both clear and blood fields, with subsequent video analysis by 8 surgeons via questionnaire. RESULTS: The HD-DS had a higher resolution than the SD-DS and the FO at both 20 mm (6.35 vs 4.00 vs 2.24 line pairs/mm) and 10 mm (14.3 vs 7.13 vs 4.00 line pairs/mm) evaluations, respectively (P <.001 and P <.001). Color representation and depth of field (P = .001 and P <.001) were better in the HD-DS. When compared to the FO, the HD-DS and SD-DS demonstrated superior deflection up and irrigant flow with and without accessory present in the working channel, whereas image brightness was superior in the FO (P <.001, P = .001, and P <.001, respectively). Observers deemed the HD-DS cystoscope superior in visualization in clear and bloody fields, as well as for illumination. CONCLUSION: The new HD-DS provided significantly improved visualization in a clear and a bloody field, resolution, color representation, and depth of field compared to SD-DS and FO. Clinical correlation of these findings is pending.

In vitro comparison of a novel facilitated ultrasound targeting technology vs standard technique for percutaneous renal biopsy.

OBJECTIVE: To improve the understanding of the epidemiology of renal cortical neoplasms through pretreatment biopsy, we evaluated a facilitated ultrasound targeting (FUT) technology. The technology allows a needle to be passed through the transducer probe and guided along a virtual dotted line on the monitor. We compared the FUT with standard percutaneous biopsy (PB) technique. MATERIALS AND METHODS: Forty-eight participants with various levels of training were recruited. Participants performed ultrasound-guided biopsies on phantom models using FUT and the standard biopsy technique in a randomized sequence. The phantom models consisted of pimento olives embedded in an opaque mold of Metamucil and Knox gelatin. Patients were given up to 10 attempts to achieve 3 complete specimens from the olives. Patients rated each biopsy technique. Results were stratified by level of experience. RESULTS: The mean time to obtain 3 complete biopsy specimens was significantly faster for FUT compared with the standard technique (140 seconds vs 246 seconds, P = .0001). The mean number of attempts needed to obtain 3 specimens was significantly less with FUT compared with the standard technique (4.3 vs 5.6 attempts, P = .0007). Patients reported that FUT was significantly easier to use compared with the standard technique (P = .0005). No significant order effect was observed. CONCLUSION: In this in vitro comparison, FUT increased the efficiency and efficacy of PB for users of all experience levels. FUT may allow urologists with limited PB experience to perform the procedure reliably and easily. Clinical evaluation of this technology is actively in progress.

Interobserver reliability and reproducibility of s.T.o.N.e. Nephrolithometry for renal calculi.

PURPOSE: To assess the reliability of the S.T.O.N.E. (stone size [S], tract length [T], obstruction [O], number of involved calices [N], and essence or stone density [E]) nephrolithometry scoring system by testing its reproducibility between different observers. PATIENTS AND METHODS: Preoperative images of 58 patients who underwent percutaneous nephrolithotomy (PCNL) were reviewed. Medical students, urology residents, one fellow, and a urology attending independently reviewed all images and scored the renal stones. Interobserver reliabilities of the total score for all categories and each component were evaluated by the intraclass correlation (ICC) and a κ coefficient. RESULTS: The interobserver reliability for the total score demonstrated high correlations for all components and total score (ICC=S, T, O, N, E and total 0.80, 0.97, 0.89, 0.84, 0.91, and 0.87, respectively). κ rates for individual components between two medical students were 0.36, 1, 0.31, 0.45, 0.33, and 0.30 for the S, T, O, N, E components and total score, respectively. κ values between the two urology residents were 0.71, 1, 0.92, 0.79, 0.93, and 0.67 for S, T, O, N, E components and total score, respectively. κ values between the urology fellow and an attending physician were 0.95, 1, 0.88, 0.94, 0.89, and 0.87 for S, T, O, N, E components and total score, respectively. P value for all the scoring components was <0.05, indicating that the estimated κ was not a result of chance. CONCLUSIONS: The S.T.O.N.E. nephrolithometry has excellent interobserver reliability. Quantifying the S and N metrics was the most challenging and least reliable. Standardized protocols to measure these components should be considered to improve accuracy and reproducibility of the scoring system.

In vitro randomized comparison of a standard and novel echogenic needle for ultrasonography-guided renal targeting.

BACKGROUND AND PURPOSE: Urologists are becoming increasingly aware of the importance of pretreatment percutaneous renal biopsy of small renal cortical neoplasms. A barrier to the routine performance of ultrasonography-guided percutaneous renal biopsy has been the technical challenges associated with the procedure. We evaluated a new modified needle, which incorporates an echogenic needle tip designed to improve the needle tip's visibility under ultrasonographic visualization. We evaluated and compared the ultrasonographic imaging quality of the echogenic needle (EN) and a standard needle (SN). METHODS: Forty-eight participants were recruited to perform ultrasonography-guided needle targeting and drainage of a simulated cyst within a phantom model. The simulated cysts were embedded in an opaque gel mold. Each participant was blinded to the type of needle being deployed and was asked to identify and aspirate the simulated cyst with each needle under ultrasonography guidance. Each needle was tested at three ultrasound-aiming angles, (0, 15, and 30 degrees). The quality of needle visibility under ultrasonographic imaging was assessed via a questionnaire, including needle preference and a visibility score (1-10) at each aiming angle. Participants were stratified by level of ultrasound experience. RESULTS: For each angle tested, the EN received higher visibility ratings. The mean visibility scores for the EN vs the SN were 6.44 vs 5.52 at 0 degrees (P=0.001), 7.77 vs 6.96 at 15 degrees (P=0.0004) and 8.33 vs 7.54 at 30 degrees (P=0.0001). Participants reported significantly greater comfort using the EN needle compared with the SN (P=0.001). These results held true regardless of the sequence of needle tested first. Also, there was a significant difference in visibility scores by angle (P=0.0001). Larger angles (30>15>0) resulted in higher scores. CONCLUSIONS: In this in vitro trial, the application of the EN improved needle visibility for users of all levels of experience. Clinical correlation is pending.