The sexual and gender minority (LGBTQ+) medical trainee: the journey through medical education.

In this literature overview, we share with the reader challenges faced by LGBTQ + individuals pursuing medical education, from undergraduate to postgraduate training. The LGBTQ + acronym has evolved to encompass the diverse spectrum of sexual orientation and gender identities. Recently, the term "Sexual and Gender Minority" (SGM) has emerged as an umbrella term to provide consistency in research advancing SGM health. The unique obstacles LGBTQ + trainees encounter are highlighted throughout this article, including external factors influencing career decisions, a lack of LGBTQ + healthcare curricula, discriminatory social interactions, limited mentorship opportunities, and a higher mental health burden. These challenges have the capacity to affect educational experiences, personal well-being, and professional growth. Additionally, we examine the impact of inclusive institutional climates on LGBTQ + trainees' selection of medical schools and residency programs, as they may prioritize inclusiveness and diversity when making their choice. In postgraduate training, LGBTQ + trainees continue to face challenges, exemplified by disparities in placement rates and discriminatory experiences based on sexual orientation and gender identity. We describe the gap in current research and its long-term impact of these challenges on career paths. Hostile environments persist in certain specialties, and the lack of LGBTQ + mentorship and support can hinder academic pursuits. We shed light on the unique and pervasive challenges faced by LGBTQ + trainees throughout their medical education journey, while emphasizing the need for inclusive policies, support systems, and research to address these challenges. With increasing research and studies, we hope to create a medical workforce and community that better represents the diverse communities it serves.

Implementation and Evaluation of a Trainee Orientation Manual in an Intensive Care Unit Rotation.

Background: The intensive care unit (ICU) rotation places trainees in a fast-paced, high-intensity environment that requires complex patient care and multidisciplinary coordination. Trainees seek continuous medical knowledge acquisition while tasked with learning ICU-specific workflows, procedures, and policies. The unfamiliarity with rotation logistics and administrative roles and expectations could hinder the ICU rotation learning experience. A lack of standardization and material for trainee orientation to administrative ICU tasks and workflows could affect the trainee's rotation performance and overall learner satisfaction. Objective: We evaluated the implementation of an ICU trainee manual to provide trainees with a source of orientation for rotation logistics and nonclinical ICU tasks. We assessd its impact on content retention, learners' satisfaction with the manual, and overall ICU rotation experience. Methods: We designed an observational, prospective cohort study that included all trainees scheduled to rotate in the ICU during the 2020-2021 academic year. The ICU manual was delivered electronically and was available throughout the academic year. Trainees received a survey before their first ICU rotation (pretest) and 6 months after their first ICU rotation (retest) to assess content retention, trainees' perception of the ICU manual, and overall rotation satisfaction. Results: A total of 95 trainees completed the pretest survey, and 61 completed the retest survey. The target cohort response rate for each survey was 100%. Pretest scores were higher than the matched retest scores (41 of 48 [interquartile range, 37-44] vs. 38 of 48 [34-41]; P < 0.001). The median ICU manual satisfaction score was 32 of 40 (26-36.5). We found positive correlations between ICU manual trainee satisfaction score and the retest score (r[59] = 0.320; P = 0.01) and ICU rotation trainee satisfaction level (r[59] = 0.909; P < 0.001). Conclusion: Implementing an ICU manual to orient trainees to their ICU clinical rotation was well received and showed continued retention of orientation content. Higher ICU rotation trainee satisfaction levels were related to a positive perception of the ICU manual.

Are Chest Radiographs Routinely Indicated After Chest Tubes Placed for Non-Surgical Reasons Are Removed?

Background The insertion and subsequent removal of chest tubes are frequently performed procedures for the management of pneumothoraces, pleural effusions, and cardio-thoracic surgical interventions. A chest radiograph is commonly obtained after the removal of a chest tube to rule out the interval development of a pneumothorax. This practice has been questioned in various retrospective and prospective studies conducted on surgical patient populations, showing little to no benefits in performing routine chest X-rays (CXRs) after chest tube removal unless clinical symptoms such as worsening respiratory status and hemodynamic compromise are present. Material and Methods A four-year retrospective study was conducted using the Cleveland Clinic Foundation database. A chart review was performed, and 1,032 patients were screened, with 200 patients meeting inclusion criteria. The inclusion criteria included patients who underwent chest tube insertion for non-surgical reasons. The primary outcome was the percentage of clinically significant pneumothoraces detected by routine CXR after chest tube removal. Results Out of the 200 patients included in the study, 53 had a CXR after chest tube removal showing a residual pneumothorax. Out of the 53 patients, 50 ended up not needing chest tube re-insertion, as the patients were asymptomatic and hemodynamically stable. Only three patients required chest tube re-insertion due to respiratory symptoms and significant hemodynamic changes after the chest tubes were removed. In all three cases, the symptoms manifested prior to the CXRs being obtained; therefore, the decision to reinsert each chest tubes was made based on clinical signs rather than imaging. As expected, the practice of repeating CXRs after removal of the chest tubes resulted in delayed discharges despite patients reporting no symptoms and being hemodynamically stable. Conclusions Our study findings correlate with prior smaller studies on surgical patients. Symptoms and hemodynamic data seem to be a better predictor of whether a patient will require chest tube re-insertion or not. Routine CXR after chest tube removal also leads to prolonged hospital stay.

Pulmonary Arterial Hypertension in Hispanics.

Pulmonary hypertension (PH) is a medical condition characterized by elevated pressures in the pulmonary vessels. Pulmonary arterial hypertension (PAH), or pre-capillary PH, is a subgroup of the broader PH definition. PAH is rare compared to other groups of PH; its prevalence is about 15 cases per million in the adult population. Several disease processes may lead to PAH; however, the most common cause of PAH is idiopathic. Until recently, treatment for PAH was very limited and prognosis was dismal. Limitations in management remain present today but more treatment options are available for patients suffering from this condition.  Most of the information available regarding PAH comes from registries in the United States and Europe. Limited information about epidemiology, treatment options, and response to the treatment is available for other ethnic groups such as Hispanics. In the world of medicine, we have learned from other more common medical conditions that components, such as genetics, environment, and culture may affect how diseases manifest and how they respond to treatment. It is important to be aware of how different ethnic groups exposed to different environmental conditions respond to different treatment modalities. The aim of this paper is to review the limited data available regarding PAH in Hispanics. This paper will review the information regarding the etiology, diagnosis, and treatment modalities available in South American and Central American countries. This paper will also review the data available for Hispanics diagnosed with PAH living in the United States. The goal is to highlight the difference in how PAH manifests in Hispanics compared to other ethnic groups. We aim to emphasize the importance of the lack of data available for this group and how it may be affecting the way we are treating Hispanics with PAH.

Rare presentation of bronchopulmonary Kaposi sarcoma.

Kaposi sarcoma (KS) is an angioproliferative disorder that is commonly associated with human herpes virus 8 as well as the HIV. In fact, KS is one of the most common AIDS-defining illnesses. KS typically presents with diffuse, violaceous cutaneous nodules, and may have concomitant visceral involvement. However, visceral involvement rarely occurs without skin manifestations. A rare case of localised bronchopulmonary KS without skin involvement is described in a patient with previously undiagnosed HIV. This atypical presentation represents a challenge for modern-day physicians in developed countries where the prevalence of AIDS-related diseases is decreasing.

Spontaneous Intra-orbital Arteriovenous Fistula: A Rare Cause of Proptosis.

A left orbital arteriovenous fistula (AVF) is diagnosed in a patient presenting with proptosis. Intra-orbital AVFs are rare according to the literature search, and therefore, the best treatment modality remains controversial. We present a case of a patient who presented with non-specific symptoms. He was diagnosed with intra-orbital AVF and underwent a trans-arterial embolization. The procedure was complicated by the central retinal artery occlusion, which is one of the most feared complications associated with this procedure. We discuss the modalities in the diagnosis of intra-orbital AVFs as well as stress the importance of an interdisciplinary approach for its timely and efficient management.

Life-Threatening Pulmonary Hemorrhage Responds to Recombinant Factor VIIa: A Case Series in South Florida Hospitals.

Intravenous recombinant activated Factor VIIa (rFVIIa) is approved as a hemostatic agent for only a few bleeding disorders. Since the first reported case of off-label use for rFVIIa in 1999, off-label use far exceeds the use for approved conditions. The endobronchial administration of rFVIIa to control alveolar hemorrhage has been published in only a few case reports. Herein we report a case series of endobronchial rFVIIa use for life-threatening pulmonary hemorrhage at two institutions in south Florida.

Blow: a case of pufferfish intoxication in South Florida.

We report the case of a 43-year-old African American man with a history of hypertension and chronic kidney disease presenting with hypertensive emergency and bulbar paralysis in a descending fashion, which ultimately led to acute respiratory failure. He ingested pufferfish liver during the preceding 4 hours prior to presentation, as well as canned foods and cocaine over the prior 3 days. He had a complicated hospital course requiring intubation and mechanical ventilation, as well as the development of acute respiratory distress syndrome and acute renal failure requiring haemodialysis. This case exemplifies the classic manifestations of tetrodotoxin poisoning with some unique overlapping features, in the setting of an interesting social history.