Critical Care Education and Skills Validation Course for Internal Medicine Physicians in the Military.

INTRODUCTION: Military internist and internal medicine (IM) subspecialist physicians must be prepared to function in both traditional inpatient and outpatient settings, as well as manage critically ill patients within a deployed austere environment. As many critical care procedures are not performed on a routine basis in general IM practice, many active duty IM physicians experience skills degradation and lack confidence in performing these procedures. In order to address this perceived deficiency, the U.S. Army and Air Force Internal Medicine Education and Skills Validation Course was developed to provide essential training in critical care procedures for active duty military IM physicians and subspecialists. MATERIALS AND METHODS: Staff internist and subspecialist physicians at multiple military treatment facilities participated in a 2-day simulation-based training course in critical care procedures included in the Army Individual Critical Task Lists and the Air Force Comprehensive Medical Readiness Program. Educational content included high-yield didactic lectures, multi-disciplinary Advanced Cardiac Life Support/Advanced Trauma Life Support high-fidelity simulation scenarios, and competency training/validation in various bedside procedures, including central venous and arterial line placement, trauma-focused ultrasound exam, airway management and endotracheal intubation, chest tube thoracotomy, and mechanical ventilation, among others. RESULTS: A total of 87 staff IM physicians participated in the course with an average of 2-4 years of experience following completion of graduate medical education. Upon course completion, all participants successfully achieved rigorous, checklist-based, standardized validation in all the required procedures. Survey data indicated a significant improvement in overall skills confidence, with 100% of participants indicating improvement in their ability to function independently as deployed medical officers. CONCLUSIONS: Broad implementation of this program at military hospitals would improve pre-deployment critical care procedural readiness in military IM physicians.

Development of In-situ Simulation Lab for Training Gynecology Residents in Basic Laparoscopic and Hysteroscopic Operative Skills.

INTRODUCTION: Mounting evidence suggests that practice on simulators leads to improved operative skills and patient safety. With restrictions on resident work hours resulting in less exposure to procedures, simulation is the key to developing operative skills during residency and beyond. Residency programs struggle with implementing a simulation program due to timing and availability of residents. Despite having a large centralized simulation space at our institution, we identified lack of dedicated gynecologic simulation curriculum and simulator accessibility as our greatest barriers to utilizing simulation training in gynecology resident education. We sought to design a space within the resident work area dedicated to gynecologic simulation training with specific curriculum and objectives for each work station based on residency year level. METHODS: We created four workstations in a room within the Ob/Gyn clinic, in close proximity to the resident offices. Two virtual reality simulators, the LapVR (CAE, Montreal, Canada) ($84,996.00) and Simbionix Hystsim (3D Systems, (formerly Simbionix), CO, USA) ($95,741.10), were acquired from our institution's simulation center and placed in this training space to allow for enhanced resident access. The two other work stations consisted of an FLS trainer box and monitor ($1580) and another low fidelity laparoscopic box trainer and monitor ($450). Specific objectives for each station with corresponding evaluation checklists were written for each residency year level. Dedicated time to meet the written objectives was given to residents each week during their benign gynecology rotation. Supervision and assistance with task completion was provided by staff mentors assigned during those shifts. RESULTS: Residents who had this simulation lab available to them during their gynecology rotation participated in a minimum of seven hours of simulation time in addition to the time they spent on their own in the lab. These residents felt this was a meaningful increase in the amount of laparoscopic and hysteroscopic simulation exposure by having access to this in-situ GYN Simulation Training Laboratory with a defined gynecologic curriculum. Multiple staff members also took advantage of the simulation lab to practice their skills as well. CONCLUSIONS: We created an in-situ Gyn Simulation Training Lab that allowed for both improved accessibility by the residents and ease of implementation of simulation curriculum into pre-existing resident didactic time. It is our opinion that the time residents spend engaged in surgical simulation will improve surgical skills and confidence thereby enhancing patient safety. Additionally, the creation of this in situ simulation lab assists in meeting the Accreditation Council for Graduate Medical Education (ACGME) requirements for incorporation of simulation into OB/GYN resident education.

The Dying Art of Vaginal Hysterectomy: A Novel Simulation.

The rate of vaginal hysterectomy has decreased despite the procedure being the preferred hysterectomy method according to the American College of Obstetricians and Gynecologists (ACOG). Physicians have reported that some of the main barriers to performing minimally invasive hysterectomy are the size and shape of the uterus, difficulty of accessibility to the uterus, and surgeons' lack of training and experience. A simulation model for vaginal uterine morcellation was created in an effort to increase surgeons' confidence and to encourage them to select vaginal hysterectomy for their patients. The Conner model, where polyvinyl chloride (PVC) piping is used to simulate the pelvis and vaginal canal, was used as the basis for the pelvis. A medium-density fiberboard (MDF) was used as a base, while a PVC piping structure was used to stimulate the pelvis. The uterus was created from a peanut (car-wash) sponge that was carved into a triangle shape. The reusable MDF/PVC model was built in approximately one hour and cost under USD 30. The sponge uterus was built in approximately 10 minutes and cost under USD 2. Senior residents and faculty who have previously performed uterine morcellation participated in our simulation. Resident physicians reported that they felt more confident in their skills after the simulation. Both resident and staff physicians reported that the model had created a realistic experience. We created a novel model for vaginal uterine morcellation that was reported to be realistic in the initial investigation and increased confidence in the procedure for physicians. The model is easy to create, affordable, and partially reusable.

Hemofagocitosis secundaria a dengue / Hemophagocytosis secondary to dengue fever

La infección por el virus del dengue constituye un problema de salud pública mundial. Causada por un virus de la familia Flaviviridae, presenta un amplio espectro clínico, desde formas asintomáticas frecuentes hasta las formas graves de fiebre hemorrágica y shock por fuga capilar. Existen cuatro serotipos; los serotipos 2 y 3 están asociados a las formas graves de la enfermedad. El diagnóstico definitivo de infección por dengue depende del aislamiento del virus en sangre, de la detección del antígeno viral o el ARN viral en suero o tejido, o detección de anticuerpos específicos. El síndrome hemofagocítico se produce ante la desregulación del sistema inmune que lleva a la activación macrofágica descontrolada, y se manifiesta con alteraciones clínicas, hematológicas, bioquímicas e histológicas. La asociación entre ambas entidades se encuentra descripta como una forma inusual y grave de presentación que responde a la tormenta de citocinas liberadas durante la enfermedad. Presentamos el caso de un paciente adulto con dengue, hemofagocitosis y valores inusualmente elevados de ferritina en sangre que evolucionó favorablemente con tratamiento de soporte.

Dengue virus infection constitutes a major public health problem worldwide. It is caused by a virus belonging to the Flaviviridae family. It produces a wide range of clinical presentations, from asymptomatic infection to severe forms of the disease with hemorrhagic fever or shock secondary to capillary leak syndrome. Four serotypes have been described; serotype 2 and serotype 3 are associated with the most severe forms of the disease. The diagnosis is based on laboratory tests aimed to detect antibodies, viral RNA, or antigens in serum. The hemophagocytic syndrome is generated by a dysfunction of the immune system with clinical, hematological, biochemical and histological manifestations. The association between these two entities is described as an unusual and severe presentation of dengue fever. We present a case of an adult patient with this association and very high blood levels of ferritin, who responded favorably to supportive care.

[Hemophagocytosis secondary to dengue fever]. / Hemofagocitosis secundaria a dengue.

Dengue virus infection constitutes a major public health problem worldwide. It is caused by a virus belonging to the Flaviviridae family. It produces a wide range of clinical presentations, from asymptomatic infection to severe forms of the disease with hemorrhagic fever or shock secondary to capillary leak syndrome. Four serotypes have been described; serotype 2 and serotype 3 are associated with the most severe forms of the disease. The diagnosis is based on laboratory tests aimed to detect antibodies, viral RNA, or antigens in serum. The hemophagocytic syndrome is generated by a dysfunction of the immune system with clinical, hematological, biochemical and histological manifestations. The association between these two entities is described as an unusual and severe presentation of dengue fever. We present a case of an adult patient with this association and very high blood levels of ferritin, who responded favorably to supportive care.

Characterization of Resistance Mechanisms in Faba Bean (Vicia faba) against Broomrape Species (Orobanche and Phelipanche spp.).

Faba bean (Vicia faba) production in Mediterranean and Near East agriculture is severely constrained by broomrape infection. The most widely distributed broomrape species affecting faba bean is Orobanche crenata, although O. foetida and Phelipanche aegyptiaca are of local importance. Only moderately resistant cultivars are available to farmers. Rizotrons studies allowed the dissection of resistance components in faba bean accessions against the very infective species O. crenata, O. foetida var. broteri and P. aegyptiaca, and to the inappropriate P. ramosa and O. foetida var. foetida. Results confirm that some levels of incomplete resistance are available, resulting in a reduced number of broomrape tubercles successfully formed per faba bean plant. Interestingly, the intermediate levels of resistance of cv. Baraca were operative against all broomrape populations and species studied, confirming previous reports on the stability of resistance of Baraca in field trials in different countries. Low induction of seed germination played a major role in the resistance against the inappropriate O. foetida var. foetida but not against the also inappropriate P. ramosa, neither to the infective species O. crenata, O. foetida var. broteri, or P. aegyptiaca. Negative tropism of germinated seeds with radicles growing away from faba bean roots was marked for both inappropriate species but was not observed in any of the infective species. Also, a proportion of radicles that had successfully contacted faba bean roots became necrotic, failing in starting tubercle development, particularly frequent for the two inappropriate species. Such necrosis was significant also on radicles contacting resistant faba bean accessions, being particularly relevant for Spanish O. crenata population, and lower although still significant in some accessions against Syrian O. crenata and P. aegyptiaca, suggesting that this might also be an operative mechanism to be selected and further exploited in faba bean resistance breeding. Even formed broomrape tubercles might later become necrotic, particularly in the case of some of the resistant faba bean accessions to the Spanish O. crenata and to P. aegyptiaca but not to the very infective Syrian O. crenata or O. foetida var. broteri.

Chorioamniotic Membrane Separation Found on Routine Testing in an Otherwise Asymptomatic Woman With Late Preterm Twin Gestation.

BACKGROUND: Chorioamniotic membrane separation (CMS) is a rare finding that is commonly preceded by invasive fetal procedures. The presence of CMS can also be associated with uncommon maternal or fetal conditions as well as preterm delivery, amniotic band syndrome, umbilical cord complications, and fetal and neonatal death. It is classified as a high-risk antepartum condition due to the significant fetal morbidity and mortality that may ensue. CASE REPORT: A 40-year-old gravida 5 para 1212 at 35 weeks presented for antepartum fetal testing. Her antepartum course was complicated by di-di twin gestation, chronic hypertension, and advanced maternal age. A routine ultrasound (as part of the antepartum fetal testing) identified an incidental finding of CMS. The patient's only reported symptom was that of preterm contractions, without evidence of active labor, and other fetal testing was reassuring. She had a repeat cesarean section that day and the suspected etiology was preterm, premature rupture of membranes of Twin B that was seen on entry into the uterine cavity. DISCUSSION: Chorioamniotic separation is a rare occurrence associated with significant adverse fetal outcomes. This is the first reported case of incidental diagnosis in a twin pregnancy during antepartum fetal surveillance testing. Our detection resulted in the delivery of late preterm, but otherwise healthy, twin neonates.