A 58-year-old female presented with leg paresthesia and rash. On presentation, the rash was most consistent with cellulitis and cephalexin was started. The next day vesicles appeared which were presumed to be shingles and acyclovir was started. They evolved into a fully necrotic lesion on day 4 and had the classic presentation of a brown recluse spider bite. Bite marks were missed at presentation. Brown recluse spider bites are commonly misdiagnosed 80% of the time. Brown recluse venom contains a variety of toxins which can lead to skin necrosis (37% of patients) that occurs via an unknown mechanism dependent on host neutrophils. Skin changes progress over 12–36 h and necrosis develops within several days. Treatment recommendations call for exclusion of other diagnoses and conservative management with local wound care, tetanus prophylaxis, and debridement. Other forms of treatment should be avoided. Our patient was treated with a skin graft with good results. The following core competencies are addressed in this article: Patient care and medical knowledge.

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It is common practice to assess the consistency of diagnostic ratings in terms of “agreement beyond chance.” The kappa coefficient is a popular index of agreement for binary and categorical ratings. This article focuses on the unweighted kappa statistic calculation by providing a stepwise approach that is supplemented with an example. The aim is that health care personnel may better understand the purpose of the kappa statistic and how to calculate it. The following core competencies are addressed in this article: Medical knowledge.

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Spinal cord stimulation (SCS) relies on the ability to create an overlap of paresthesia on the painful regions. Electrode implantation has historically been performed with awake intraoperative testing to allow the patient to report on the device-induced paresthesia. More recently, the use of neuromonitoring has come into favor and can be used for SCS placement, while the patient remains fully anesthetized throughout the surgery. This is a critical evaluation of the neuromonitoring technique and protocol with an in-depth description of neuromonitoring for SCS placement using electro-myography (EMG) responses in both cervical and thoracic electrode placement. There is an explanation for the interpretation of the EMG responses, as well as case reports of two patients. Neuromonitoring is used to determine myotomal coverage, as a marker that corresponds with dermatomal coverage. This article demonstrates some of the critical steps for both the surgeon and neuromonitoring group to implement this technique, as well as the clinical results of paresthesia coverage in patients. This protocol can be utilized in implementing neuromonitoring into a practice for those implanting SCS systems. The following core competencies are addressed in this article: Medical knowledge, patient care, practice-based learning and improvement, system-based practice, interpersonal and communication skills. This article addresses the gap in knowledge base to implement an approach to improve patient care and outcome.

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Clinical research is a highly specialized and rapidly evolving field of expertise. Clinical trial (CT) sites face a continually changing legal and regulatory landscape, making research conduct and program operations challenging. Despite the high number of CTs being conducted, few sources provide a comprehensive summary of key elements essential to the success of clinical trials units (CTUs). Consequently, we set out to provide a practical review on this topic based on collective experience of CT professionals from major academic medical centers. The ultimate result of our group's work is the list of “top 11” essential components of a successful academic CTU implementation. Specific topics discussed in this manuscript include financial and organizational management, new trial feasibility assessment, standardization of procedures, centralization of resources, compliance and safety monitoring, pharmacy support, patient recruitment, effective marketing, institutional support, building (and working with) diverse teams, encouraging clinician engagement, and the importance of continuing professional education. Academic CTUs able to successfully implement key components of the above 11-point program are more likely to perform better in the high-intensity, complex, extensively regulated, and competitive CT environment of today. The following core competencies are addressed in this article: Interpersonal and communication skills, medical knowledge, practice-based learning and improvement, professionalism, systems-based practice.

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Central pontine myelinolysis (CPM) is a well-recognized iatrogenic complication of rapid correction of chronic hyponatremia. Dehydration of the brain and shrinkage of the oligodendrocyte cause separation of the myelin sheath from the axons. This damage can cause the full clinical spectrum of CPM. We report a patient with pseudohyponatremia, diabetes with hyperglycemia, hepatitis C-induced liver cirrhosis, malnutrition, and hypokalemia who developed CPM. The patient had not used insulin for 3 days during which he became hyperglycemic. After reinstitution of his insulin treatment, he developed clinical signs and radiological evidence of CPM. We review the cerebral adaptive mechanisms for the prevention of cellular shrinkage and CPM. This will help identify patient population who are at an increased risk of developing CPM in the absence of hyponatremia. The following core competencies are addressed in this article: Patient care, medical knowledge.

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Accurate quantification of scholarly productivity continues to pose a significant challenge to academic medical institutions seeking to standardize faculty performance metrics. Numerous approaches have been described in this domain, from subjective measures employed in the past to rapidly evolving objective assessments of today. Metrics based on publication characteristics include a variety of easily categorized, normalized, referenced, and quantifiable data points. In general, such measures can be broadly grouped as being author-, manuscript-, and publication/journal-specific. Commonly employed units of measurement are derived from the number of publications and/or citations, in various combinations and derivations. In aggregate, these metrics are utilized to more objectively assess academic productivity, mainly for the purpose of determining faculty promotion and tenure potential; evaluating grant application/renewal competitiveness; journal/publication, and institutional benchmarking; faculty recruitment, retention, and placement; as well as various departmental and institutional performance assessments. This article provides an overview of different measures of academic productivity and scientific impact, focusing on bibliometric data utilization, including advantages and disadvantages of each respective methodological approach. The following core competencies are addressed in this article: Interpersonal skills and communication, practice-based learning and improvement, systems-based practice.

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Cocaine is the most commonly used illicit drug with life-threatening cardiovascular complications, including coronary syndrome, sudden cardiac death, hypertensive crisis, aortic dissection, and stroke. Brugada pattern is a known complication of cocaine intoxication. There are, however, multiple mechanisms that can precipitate the Brugada pattern, beyond the sodium channel-blocking effect of cocaine. The various modes by which cocaine can cause Brugada pattern are discussed. Our patient presented with Brugada pattern and coronary vasospasm, both of which completely resolved with nitroglycerin. This case confirms that vasospasm of the right coronary artery can present as Brugada pattern. The following core competencies are addressed in this article: Medical knowledge, patient care.

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Cluster headache (CH) is a neurological disorder characterized by recurrent, severe headaches on one side of the head, typically around the eye that shares a component of parasympathetic autonomic symptoms. We report a 40-year-old female who presented with migraine headaches, occipital pain and experienced daily headaches behind the right eye. It was associated with lacrimation of her right eye, erythema, and ptosis, in which her eye would partially to fully close. After failure of multiple conservative measures, she was treated with a combination of bilateral occipital nerve and right supraorbital stimulation. The patient obtained significant relief from neurostimulation. She returned to work and initially was able to stop all medications. On 1-year follow-up, the patient is on preventive medication which includes Depakote. The patient continues with significant relief and has had no return of her autonomic features, including ptosis. Neurostimulation is a viable option in the treatment of CHs, including those with disabling autonomic features. The use of combined occipital nerve and supraorbital stimulation administers relief for both headache component and autonomic symptoms. The following core competencies are addressed in this article: Medical knowledge and patient care. The article addresses the lack of awareness surrounding neuromodulation, as well as expanding indications for an established therapy.

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Background: Although economic burden data of chronic obstructive pulmonary disease (COPD) and asthma for various countries are available, data among Indian population are unavailable. Thus, the aim of this study was to measure the prescription pattern and cost of illness (COI) of asthma and COPD patients. Methods: This prospective, observational, bottom-up study collected economic, diagnostic, and therapeutic data from 150 COPD and asthma patients. The study was carried out for an 8-month period at Princess Esra Hospital, a Unit of Owaisi Group of Hospitals, located at Shalibanda, Hyderabad, Telangana, India. Results: Societal perspective was used to account for both direct and indirect costs. Asthma and COPD account for Rs. 12,852 and Rs. 16,514 in annual direct costs per patient per year. Inpatient cost was considerably higher than the outpatient cost. Hospitalization costs ranked first in direct costs followed by laboratory examination and medication costs. Average annual total direct cost per patient for COPD (Rs. 5000–25,000) was considerably higher than asthma (Rs. 1000–20,000). Antibiotics, mucolytics, short-acting beta-2 agonists, long-acting beta-2 agonists, long-acting muscarinic antagonists, leukotriene receptor antagonists, corticosteroids, antihistamines, and methylxanthines were the common categories of drugs prescribed for the two disorders. Conclusion: In summary, we found that COI for asthma and COPD are substantial. Hospitalization and medication costs can be reduced by implementing preventive strategies including but not limited to home care services, rehabilitation therapies, smoking cessation programs, medication assessment, and patient compliance programs. Future researchers should examine the treatment strategies and interventions that may help to reduce the burden of COPD and asthma. The following core competencies are addressed in this article: Patient care, practice-based learning and improvement, systems-based practice.

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A 26-year-old female presented with progressive abdominal distension and oliguria in puerperal period. Diagnosis of spontaneous intraperitoneal rupture of bladder following normal vaginal delivery was made based on the clinical and radiological features. Computed tomography (CT) cystogram suggested the rents in the dome and posterior wall of the urinary bladder and the defects were repaired. She developed multiple complications such as urinary tract infection, sepsis, bacterial peritonitis, and intestinal adhesions. In the presence of large urinary ascites, oliguria, and renal failure in puerperal period, bladder rupture should be considered. Emergency physician should establish the diagnosis early and urgent operative repair has to be performed to reduce complications and morbidity. The following core competencies are addressed in this article: Medical knowledge, patient care.

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We present a case of a 77-year-old man admitted for chronic anemia secondary to recurrent gastrointestinal (GI) bleeding due to angiodysplasia with aortic stenosis (AS). Our patient was diagnosed with Heyde's syndrome. We review Heyde's syndrome, a combination of an acquired deficiency of the largest multimers of von Willebrand's factor (vWF) (Type 2A deficiency), bleeding angiodysplasia, and AS. AS causes high shearing forces on vWF, provoking changes in its shape that promote its cleavage, which further impairs the clotting ability of platelets. These patients are prone to clinically significant GI bleeds. Medical therapy offers little long-term benefit. Aortic valve replacement (AVR) frequently provides resolution of recurrent bleeds in up to 93% of patients. Recurrent bleeding in Heyde's syndrome is not an indication for AVR in the absence of symptomatic AS. AVR should be seriously considered in all cases of Heyde's syndrome. The following core competencies are addressed in this article: Patient care and medical knowledge.

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Introduction: Gaps remain in what constitutes optimal healthcare team training in terms of design and impact. This study utilizes a parallel group randomized design to study the impact of a modified TeamSTEPPS training on resident and nurse attitudes toward teamwork and their adherence to patient safety (PS) protocols. Methods: The intervention randomized 76 participants (38 nurses and 38 1^st year residents) equally into one of four parallel training groups to receive central venous catheter (CVC) lines simulation training with and without a modified 1-h TeamSTEPPS training. Both groups participated in video-based CVC instruction and a simulation CVC case scenario using high-fidelity mannequins. Participants were randomized twice: Initially into TeamSTEPPS and non-TeamSTEPPS training groups using a computer-generated randomization list, and then into resident-nurse pairs prior to the simulation CVC case scenario by selecting room assignments out of a hat. At the conclusion of a training session, participants completed the TeamSTEPPS questionnaire to measure perceptions for teamwork. Resident/nurse pairs' adherence to PS protocols during the simulation CVC case were recorded by the laboratory's audio/video system to measure team performance. Three trained and blinded postdoctoral research associates scored all recordings independently. Residents were eligible for the study if they were a 1^st year postgraduate trainees with no prior TeamSTEPPS training. Nurses were eligible if they had <5 years of Intensive Care Unit experience and no prior TeamSTEPPS training. The principal investigator recruited volunteers through the hospital's E-mail system. Consent was obtained prior to training via E-mail and again at the start of each session. The setting was an independent teaching hospital in an urban setting that trains approximately 400 house staff. Results: Repeated-measures analyses of variance showed significant differences in attitudes of teamwork between groups. However, there was no significant difference in adherence to safety markers between groups. There was high, >70% exact agreement among the three raters. Exploratory analyses revealed that team behaviors predicted adherence to PS protocols. No adverse events or side effects were observed or reported. Conclusions: This study found that a modified TeamSTEPPS training improved resident and nurse attitudes of teamwork. However, this improvement did not translate into differences between groups with and without the TeamSTEPPS training in their adherence to PS protocols. Additional research is needed to determine the optimal team-training designs that improve PS. This research was funded by a research grant from the Albert Einstein Society, Philadelphia, PA, and was approved for exemption by Einstein Medical Center Philadelphia campus's Institutional Review Board. The authors report no declarations of interest. The following core competencies are addressed in this article: Medical knowledge, interpersonal and communication skills, patient care, practice-based learning and improvement, professionalism, and systems-based practice.

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Abdominal desmoid tumors (ADTs) are rare, fast-growing, nonmalignant tumors of the soft tissue. ADTs have no known metastatic potential; however, they are locally aggressive and may result in local tissue destruction. The diagnosis of an ADT should be considered in a female patient with a prior history of pregnancy and previous abdominal surgery who presents with a painless intra-abdominal mass. We present the case of a 23 cm intra-ADT excision in a 40-year-old African American female requiring abdominal wall reconstruction with component separation. We also discuss a comprehensive review of the literature including current treatment methods and prognostic outcomes in patients following the resection of ADTs. An individualized multi-modality treatment approach employing both surgical and medical therapy to achieve histologically negative margins appears to be the most effective treatment strategy to reduce the recurrence rate of ADTs. The following core competencies are addressed in this article: Patient care and medical knowledge.

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Central nervous system manifestations of pheochromocytomas usually result from hypertension, hemorrhage, and tumors when it is part of heritable syndromes. We describe a unique case where obvious causes are lacking for an ischemic stroke. Recent advances in cell biology have elucidated the role of endothelium and vascular smooth muscle cell in vascular flow regulation. We propose a novel mechanism for an increased risk of ischemic stroke that occurs during the hyperadrenergic state. New pharmacological agents used to treat stroke that act on the various pathways proposed in our mechanism are reviewed. The following core competencies are addressed in this article: Patient care and medical knowledge.

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Context: Both hyperglycemia and hypoglycemia can significantly impact outcomes in critically ill patients. In the Intensive Care Unit (ICU), hypoglycemia is often the result of intensive insulin therapy. Aims: The purpose of this study is to assess the impact of insulin infusion associated hypoglycemia using a multidisciplinary quality improvement approach with targeted education and real-time follow-up in a surgical ICU. Setting and Design: A concurrent study in a surgical ICU of an academic medical center. Materials and Methods: Our clinical pharmacists concurrently reviewed all cases of hypoglycemia (glucose <74 mg/dL) from March 16, 2010, to March 15, 2011. For cases of hypoglycemia judged related to insulin infusions, the pharmacists and unit clinical nurse specialists reviewed each case for compliance with institutional guidelines, and unit clinical nurse specialists or nurse managers provided targeted education to the bedside nurses involved. In August 2010, we performed unit wide nursing education on glycemic control and the insulin infusion guideline. Causes of hypoglycemic events were compared before and after education was completed. Statistical Analysis: Fisher's exact test for nominal data. Results: Four hundred and twenty-nine hypoglycemic events (188 patients) occurred in 2233 patient admissions. Most events involved administration of insulin (40%), including 106 (25%) involving insulin infusions and 59 (14%) associated with sliding scale insulin administration. Education significantly reduced the percentage of hypoglycemic events due to noncompliance (47% pre vs. 17% post, P = 0.002). Conclusions: Education and unit feedback with concurrent staff follow-up were associated with a significant reduction in the rate of hypoglycemic events. The following core competencies are addressed in this article: Patient care, practice-based learning and improvement.

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Background and Objectives: Published evidence suggests that colorectal laparoscopic surgery is similar to conventional open surgery in terms of oncological safety. Here, we describe our experience performing a laparoscopic right hemicolectomy with an intracorporeal anastomosis using endostaplers (LRH-IAE). Methods: A retrospective review of patients who underwent LRH-IAE from February 2008 to May 2012 was performed. Demographic, intraoperative, and postoperative data were collected. Key end-points included open conversion rates, adequacy of oncologic resection, and 30-day morbidity and mortality. Results: A total of 27 LRH-IAE procedures were performed during the study period. Median patient age was 74 years, with 12 females and 15 males. Most common indications for surgery included colonic mass (74.1%, n = 20) and incomplete polypectomy (14.8%, n = 4). The median American Society of Anesthesiologists score was 3 (interquartile range [IQR]: 2–3) and median operative time was 312 min (IQR: 200–420 min). There were no conversions to open laparotomy. Surgical margins were negative in all patients, with a median of 17 lymph nodes examined per specimen. Nine patients experienced postoperative morbidity, including cardiac (7.4%, n = 2), pulmonary (18.5%, n = 5), and abdominal (22.2%, n = 6) complications. Abdominal complications included ileus (3.7%, n = 1), perforated viscus/leak (7.4%, n = 2), anastomotic stricture (3.8%, n = 1), and an incisional hernia (7.4%, n = 2). All-cause 30-day mortality was 11.1% (3/27). The median length of stay was 5 days (range: 3–42 days). Conclusion: This report shows that LRH-IAE in high-risk surgical population is characterized by an acceptable risk-benefit profile. LRH-IAE offers the advantages of less tissue manipulation and adheres to established oncological principles. The following core competencies are addressed in this article: Medical knowledge and patient care.

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Abdominal pain is a common chief complaint and requires a broad differential diagnosis, particularly in the elderly. Certain diagnoses come to mind immediately when evaluating for causes of abdominal pain, but gallstone ileus is not always among those first considered. However, given the high mortality rate it carries, gallstone ileus should be considered in patients with obstructive symptoms, particularly those over the age of 65. The following discussion outlines a case of gallstone ileus and illustrates the classic radiographic finding, known as Rigler's triad, associated with this disease process. The following core competencies are addressed in this article: Medical knowledge, patient care, practice-based learning and improvement, and systems-based practice.

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Both traumatic and nontraumatic hemorrhagic shock continues to be associated with unacceptably high mortality and morbidity. Although significant progress has been made within the transfusion science in terms of research and subsequent implementation of life-saving massive transfusion protocols, controversies persist regarding the optimal fresh frozen plasma-to-packed red blood cell (FFP-to-PRBC) ratios in the setting of hemorrhagic shock resuscitation, especially in the context of postresuscitation sequelae. To further compound the problem, there continues to be a paucity of prospective and high-quality retrospective data in this important clinical area. The goal of this hypothesis-generating, meta-analytic study was to combine data from all available high-quality literature sources in order to enhance our understanding of the relationship between FFP-to-PRBC ratios and associated morbidity/mortality across the entire reported spectrum of transfusion component combinations. Major findings of this analysis include the significant association between increasing FFP-to-PRBC ratios and decreasing mortality, as well as the concurrent increase in morbidity among survivors. More specifically, mortality odds were significantly lower with “higher” versus “lower” FFP-to-PRBC ratios (odds ratio [OR] 0.569; 95% confidence interval [CI] 0.463–0.700) in a combined cohort of 10,610 patients. At the same time, multi-organ failure was more likely to occur in the “higher” FFP-to-PRBC ratio group (OR 1.417, 95% CI 1.243–1.616). Formal studies that focus on risk-benefit aspects of higher FFP-to-PRBC ratios are needed. Research efforts should be directed at continued mortality reduction following massive transfusion while focusing on strategies designed to minimize the incidence and severity of complications among survivors of hemorrhagic shock. The current study provides a potentially useful platform for planning and implementation of future research efforts in the area of damage control resuscitation. The following core competencies are addressed in this article: Patient care, practice-based learning and improvement, systems based practice, medical knowledge

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After head trauma, thoracic trauma is the most common cause of trauma-related death. Although only a fraction of thoracic trauma cases require operative exploration, these have high mortality risk. We advocate a multi-disciplinary approach to these complex patients, with early consideration of formal cardiothoracic surgical involvement. Some argue that many of the most severe penetrating cardiac injuries will not survive to hospital presentation and of those that survive, clearly a multi-disciplinary approach to each patient's unique problem is justified. The following core competencies are addressed in this article: Patient care, professionalism, interpersonal and communication skills, systems-based practice.

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