Esophageal Rupture Presenting with ST Segment Elevation and Junctional Rhythm Mimicking Acute Myocardial Infarction.

Esophageal rupture is a rare but potentially fatal cause of chest pain. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). A 71-year-old male with a history of coronary artery disease presented to the ED with complaints of acute chest pain and respiratory distress. Over the next 48 hours, the patient developed dynamic ST segment changes on surface electrocardiogram mimicking an inferolateral ST segment elevation MI accompanied by a junctional rhythm. Curiously, his cardiac enzymes remained negative during this time, but his clinical status continued to deteriorate. A subsequent CT scan demonstrated a lower esophageal rupture, and the patient underwent successful endoscopic stenting. While rare, prompt recognition of esophageal rupture is imperative to improving morbidity and mortality. While esophageal rupture has been noted to cause ST segment elevation before, this appears to be the first case associated with a junctional rhythm.

Improved compliance with reporting standards: A retrospective analysis of Intersocietal Accreditation Commission Nuclear Cardiology Laboratories.

BACKGROUND: In 2011, Tilkemeier et al reported significant nuclear cardiology laboratory noncompliance with reporting standards. The aim of this study was to identify and examine noncompliant reporting elements with the Intersocietal Accreditation Commission Nuclear/PET (IAC) Reporting Standards and to compare compliance between 2008 and 2014. METHODS: This was a retrospective study of compliance with 18 reporting elements utilizing accreditation findings from all laboratories applying for accreditation in 2008 and 2014. RESULTS: 1816 labs applying for initial or subsequent accreditation were analyzed for compliance. The mean reporting noncompliance per lab decreased from 2008 to 2014 (2.48 ± 2.67 to 1.24 ± 1.79, P < .001). Noncompliance decreased across lab types, labs with Certification Board of Nuclear Cardiology physicians on staff, and by geographic region (P < .001). Overall severity of reporting issues decreased. Facilities with compliant reports increased from 35.0% in 2008 to 57.1% in 2014 (P < .001). CONCLUSION: Continuing medical education, accreditation, and other instructional activities aimed at improving nuclear cardiology reporting appear to have made a positive impact over time with the number and severity of noncompliance decreased. More labs are now compliant with the IAC Standards and, thus, reporting guidelines. However, the need for continued educational efforts remains.

Improving compliance with Intersocietal Accreditation Commission (IAC) reporting standards: A serial comparison of 523 labs over seven years.

BACKGROUND: The aim of this study was to evaluate reporting compliance of laboratories applying for serial accreditation by the Intersocietal Accreditation Commission (IAC) and compare compliance based on laboratory characteristics. METHODS: All laboratories applying for IAC accreditation for the first time in 2008 and then twice more (2011-2014) were evaluated for compliance with 18 reporting elements. The elements were ranked into three severity groups (high/moderate/low). RESULTS: Reports from 523 laboratories were evaluated. The percentage of laboratories with reporting issues by cycle was 66.2% for cycle 1, 36.7% for cycle 2, and 43.8% for cycle 3 (p < .001). For most of the 18 elements, there was a significant decrease in the percentage of labs with issues. Less moderate and high severity errors were seen over time. Also, the mean non-compliant elements per laboratory decreased from 5.78 ± 2.72 at cycle 1, down to 1.25 ± 1.77 at cycle 3. CONCLUSIONS: In facilities applying for 3 consecutive IAC accreditation cycles, reporting compliance with IAC Standards improved between cycles 1-2 and 1-3. No significant improvement occurred between cycles 2-3. Although the quality of reports improved overall, problems remain in quantifying myocardial perfusion defects, documenting report approval date, and integrating stress and imaging reports.

Competency in chaos: lifesaving performance of care providers utilizing a competency-based, multi-actor emergency preparedness training curriculum.

OBJECTIVE: Providing comprehensive emergency preparedness training (EPT) to care providers is important to the future success of disaster operations in the US. Few EPT programs possess both competency-driven goals and metrics to measure performance during a multi-patient simulated disaster. METHODS: A 1-day (8-hour) EPT course for care providers was developed to enhance provider knowledge, skill, and comfort necessary to save lives during a simulated disaster. Nine learning objectives, 18 competencies, and 34 performance objectives were developed. During the 2-year demonstration of the curriculum, 24 fourth-year medical students and 17 Veterans Hospital Administration (VHA) providers were recruited and volunteered to take the course (two did not fully complete the research materials). An online pre-test, two post-tests, course assessment, didactic and small group content, and a 6-minute clinical casualty scenario were developed. During the scenario, trainees working in teams were confronted with three human simulators and 10 actor patients simultaneously. Unless appropriate performance objectives were met, the simulators "died" and the team was exposed to "anthrax." After the scenario, team members participated in a facilitator-led debriefing using digital video and then repeated the scenario. RESULTS: Trainees (N = 39) included 24 (62%) medical students; seven (18%) physicians; seven (18%) nurses; and one (3%) emergency manager. Forty-seven percent of the VHA providers reported greater than 16 annual hours of disaster training, while 15 (63%) of the medical students reported no annual disaster training. The mean (SD) score for the pre-test was 12.3 (3.8), or 51% correct, and after the training, the mean (SD) score was 18.5 (2.2), or 77% (P < .01). The overall rating for the course was 96 out of 100. Trainee self-assessment of "Overall Skill" increased from 63.3 out of 100 to 83.4 out of 100 and "Overall Knowledge" increased from 49.3 out of 100 to 78.7 out of 100 (P < .01). Of the 34 performance objectives during the disaster scenario, 23 were completed by at least half of the teams during their first attempt. All teams except one (8 of 9) could resuscitate two simulators and all teams (9 of 9) helped prevent anthrax exposure during their second scenario attempt. CONCLUSIONS: The 1-day EPT course for novice and experienced care providers recreated a multi-actor clinical disaster and enhanced provider knowledge, comfort level, and EPT skill. A larger-scale study, or multi-center trial, is needed to further study the impact of this curriculum and its potential to protect provider and patient lives.

Can coronary artery anomalies be detected on CT calcium scoring studies?

PURPOSE: To determine whether coronary artery anomalies can be detected on noncontrast computed tomography (CT) coronary artery calcium scoring (CCS) studies. MATERIALS AND METHODS: A total of 126 patients (mean age 62 years; 35 women) underwent noncontrast CCS and contrast enhanced coronary CT angiography (cCTA). Thirty-three patients were diagnosed with a coronary anomaly on cCTA, whereas coronary anomalies were excluded in 93. Two observers (reader 1 [R1] and reader 2 [R2]), blinded to patient information independently evaluated each CCS study for: 1) visibility of coronary artery origins, 2) detection of coronary anomalies, and 3) benign or malignant (ie, interarterial) course. Using cCTA as the reference standard, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CCS studies for detecting coronary anomalies were calculated. RESULTS: Of the 33 coronary anomalies, 16 were benign and 17 malignant. Based on noncontrast CCS studies, R1 and R2 correctly identified the left main origin in 123/126 (97.6%) and 121/126 (96%) patients; the left anterior descending origin in 125/126 (99.2%) and 122/126 (96.8%); the circumflex origin in 120/126 (95.2%) and 105/126 (83.3%); and the right coronary artery origin in 117/126 (92.9%) and 103/126 (81.7%), respectively. R1 and R2 identified 34 and 27 coronary anomalies and classified 19 and 15 as malignant, respectively. Interobserver reproducibility for detection of coronary anomalies was good (k = 0.76). Interobserver agreement for detection of malignant variants was even stronger (k = 0.80). On average, coronary artery anomalies were diagnosed with 85.2% sensitivity, 96.4% specificity, 90.5% PPV, and 94.1% NPV on noncontrast CCS studies. CONCLUSION: Benign and malignant coronary artery anomalies can be detected with relatively high accuracy on noncontrast-enhanced CCS studies. CCS studies should be reviewed for signs of coronary artery anomalies in order to identify malignant variants with possible impact on patient management.

High-fidelity multiactor emergency preparedness training for patient care providers.

BACKGROUND: Providing comprehensive emergency preparedness training (EPT) for patient care providers is important to the future success of emergency preparedness operations in the United States. Disasters are rare, complex events involving many patients and environmental factors that are difficult to reproduce in a training environment. Few EPT programs possess both competency-driven goals and metrics to measure life-saving performance during a multiactor simulated disaster. METHODS: The development of an EPT curriculum for patient care providers-provided first to medical students, then to a group of experienced disaster medical providers-that recreates a simulated clinical disaster using a combination of up to 15 live actors and six high-fidelity human simulators is described. Specifically, the authors detail the Center for Health Professional Training and Emergency Response's (CHPTER's) 1-day clinical EPT course including its organization, core competency development, medical student self-evaluation, and course assessment. RESULTS: Two 1-day courses hosted by CHPTER were conducted in a university simulation center. Students who completed the course improved their overall knowledge and comfort level with EPT skills. CONCLUSIONS: The authors believe this is the first published description of a curriculum method that combines high-fidelity, multiactor scenarios to measure the life-saving performance of patient care providers utilizing a clinical disaster scenario with > 10 patients at once. A larger scale study, or preferably a multicenter trial, is needed to further study the impact of this curriculum and its potential to protect provider and patient lives.

Segregation of two spectrin isoforms: polarized membrane-binding sites direct polarized membrane skeleton assembly.

Spectrin isoforms are often segregated within specialized plasma membrane subdomains where they are thought to contribute to the development of cell surface polarity. It was previously shown that ankyrin and beta spectrin are recruited to sites of cell-cell contact in Drosophila S2 cells expressing the homophilic adhesion molecule neuroglian. Here, we show that neuroglian has no apparent effect on a second spectrin isoform (alpha beta H), which is constitutively associated with the plasma membrane in S2 cells. Another membrane marker, the Na,K-ATPase, codistributes with ankyrin and alpha beta spectrin at sites of neuroglian-mediated contact. The distributions of these markers in epithelial cells in vivo are consistent with the order of events observed in S2 cells. Neuroglian, ankyrin, alpha beta spectrin, and the Na,K-ATPase colocalize at the lateral domain of salivary gland cells. In contrast, alpha beta H spectrin is sorted to the apical domain of salivary gland and somatic follicle cells. Thus, the two spectrin isoforms respond independently to positional cues at the cell surface: in one case an apically sorted receptor and in the other case a locally activated cell-cell adhesion molecule. The results support a model in which the membrane skeleton behaves as a transducer of positional information within cells.

Measuring standards of care for early breast cancer in an insured population.

PURPOSE: To demonstrate the use of a combined data base to evaluate the care for local/regional invasive breast cancer in a large insured population of women aged less than 64 years. PATIENTS AND METHODS: We linked the procedural and hospital claims from Blue Cross Blue Shield (BCBS) of Virginia with clinical stage data from the Virginia Cancer Registry (VCR) from 1989 to 1991. A total of 918 women were assessed with a median age of 50 years; 68% had tumors less than 2 cm, 30% had positive axillary nodes, and 68% were assessed as having local summary stage. A quality-of-care "report card" was used based on standards of care from international Consensus Conferences. RESULTS: Eight percent had a mastectomy as the initial biopsy procedure. Sixty-nine percent of women ultimately underwent mastectomy. Of those women who underwent lumpectomy, 86% had subsequent radiation. Within 3 months of diagnosis, 43% had a bone scan and 20% a computed tomography (CT) scan. Of women with positive axillary lymph nodes, 83% aged less than 51 years and 52% aged 51 to 64 years received chemotherapy. Fifty-six percent of all women had claims from a medical oncologist. Of women having a total mastectomy, 27% had claims from a plastic surgeon. Sixty-six percent to 76% of women had a mammogram, 24% a bone scan, and 14% a CT scan in the 0-18 and 18-36 month intervals following primary treatment. CONCLUSION: This study confirms the feasibility of linking sources of data that provide complementary information needed to develop measurements regarding standards of quality and efficiency of oncologic care. This report should serve as an initial benchmark while we await reports from other populations to define the best practice.