Acute perioperative abdominal complications of ventriculoperitoneal shunt placement are generally well understood and managed by general surgeons. Delayed complications occur at nontrivial rates and can masquerade as a variety of typical diagnoses such as adhesive bowel obstruction. In some rare cases, the presentation is quite unusual with the shunt protruding from the anus or urethral meatus. Preexisting neurologic conditions often make the history and examination less reliable. Diagnostic and treatment delay can have devastating effects. The variability of these delayed presentations and problems does not allow for evaluation protocols, and the care of these patients must be individualized. General surgery principles continue to apply and, combined with a high index of suspicion, will lead the surgeon to the appropriate diagnosis and treatment options. The barrier is a failure to consider the shunt as the source of the problem when its placement was not recent. A review of the literature and presentation of an unusual case highlight several of the common delayed presentations, diagnoses, and management options. The following core competencies are addressed in this article: Patient Care, Medical Knowledge, System-based Practice.

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Raynaud's phenomenon (RP) is a multi-etiological vasospastic condition requiring individualized treatment. This case presents a patient with classic primary RP whose symptoms improved after being treated for depression. Her example demonstrates that medication regimen sometimes have unexpected, but positive outcomes. The following core competencies are addressed in this article: Patient care, Medical knowledge.

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Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure with both diagnostic and therapeutic indications. Following wider adoption of magnetic resonance cholangiopancreatography and endoscopic ultrasound, a shift emerged toward the interventional use of ERCP. Inherent to this shift was the evolution of procedural risk profile, resulting in a greater propensity for more severe periprocedural morbidity. Because ERCPs are so ubiquitous, it is imperative for medical and surgical practitioners to posses excellent knowledge of the risks, benefits, and therapeutic/diagnostic alternatives. The intent of the current manuscript is to provide an authoritative review on the topics of ERCP-related complications, emergencies, and related subject matter. The following core competencies are addressed in this article: Patient care and procedural skills, Medical knowledge, Practice-based learning and improvement.

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The purpose of this review is to provide evidence-based, standardized recommendations on intervention for pericardial effusions. The appropriate management strategy is determined by effusion etiology. Pericardiocentesis under echocardiographic or fluoroscopic guidance is recommended for acute viral or idiopathic pericardial effusions. Due to recurrence risk, indwelling pericardial catheter placement is recommended for malignant pericardial effusions. Intrapericardial instillation of sclerosing or antineoplastic agents and percutaneous balloon pericardiotomy are alternative strategies. If less invasive options are not feasible or successful, pericardiotomy may be considered. Wide anterior pericardiectomy is indicated for relapse after repeated drainage. Potential procedural risks and therapeutic benefits are considered in determining the approach to intervention. The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge, and Patient care.

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Introduction: Unrecognized clinical patient deterioration (CPD) is a precursor to preventable morbidity and mortality among hospitalized patients. The current standard of intermittent vital signs and physical assessments is inadequate for detecting early CPD and thus prevention of cardiopulmonary events. Continuous oximetry monitoring using a SafetyNet monitoring system (SNMS) may help facilitate early recognition of CPD and early intervention. However, some of the concerns regarding continuous monitoring systems include cost and alarm fatigue. We hypothesized that deployment of SNMS at our institution would result in improved detection of patient deterioration, fewer Intensive Care Unit (ICU) transfers, and reduced telemetry usage. Methods: We conducted a post hoc analysis of data from a quasi-experimental quality improvement project that took place on medical-surgical units (MSUs) at a large, tertiary referral center between January 1, 2015, and December 31, 2016. The 24-month study period included a 12-month pre-SNMS period (January–December 2015) and a 12-month post-SNMS period (January–December 2016). Clinical data were collected on two adjacent MSUs (“P8” and “P9”) with “P8” serving as the control unit where SNMS was not deployed. The primary study outcome was rate of ICU transfers tracked as transfers per 1000 patient-days. Telemetry usage and nonclinical alarm burden were our secondary outcomes. Estimated cost-saving analysis was also performed based on the reduction of ICU transfers. Results: The 24-month study period encompassed 21,189 patient-days on the P9 MSU (11,702 pre-SNMS and 9487 post-SNMS) and 23,388 patient-days on the P8 MSU (13,616 pre-SNMS and 9772 post-SNMS). The median case-mix index (a measure of patient acuity based on comorbidities) was higher for P9 than P8 during the duration of the study (2.08 [interquartile range (IQR) 1.98–2.17] vs. 1.67 [IQR 1.64–1.76], respectively). The rate of ICU transfers per 1000 patient-days on the P9 MSU declined from 11.7 during preintervention period to 8.8 post-SNMS implementation (P < 0.03), whereas the comparison unit demonstrated no change. Mean telemetry usage post-SNMS implementation significantly decreased on the P9 unit (21.6 to 16.5 per 1000 patient-days, P < 0.01). Based on the observed difference of 38 ICU transfers between pre- and post-SNMS periods, the estimated cost savings for our Network were $902,386. Conclusions: The current standard of inpatient monitoring through intermittent vital sign sampling, physical examination assessments, and continuous telemetry for patients deemed to be “high-risk” is ineffective in detecting early CPD. This study suggests that implementation of SNMS may help reduce ICU transfers (and associated costs) while at the same time decreasing the reliance on telemetry monitoring. The following core competencies are addressed in this article: Interpersonal and communication skills, Practice-based learning and improvement, Systems-based practice.

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Background: Taxi drivers play a crucial role in the social and economic function of the modern society and significantly contribute to the business world and tourism. Objective: The objective of this study was to find the occupational profile of taxi drivers in the metropolitan cities in India. Materials and Methods: This cross-sectional, community-based study used a pretested questionnaire, comprising sociodemographic, working, and personal variables, and was administered by interview technique on the taxi drivers, attending the training program at the Institute of Road Traffic and Education, Faridabad. Results: Majority of the taxi drivers in our study were married (94.01%), staying in joint families (61.31%), were driving >10 years (66.56%), and working full time (96.72%) and in shifts (92.17%) when employed in organized sectors. Majority enjoyed adequate night sleep (94.43%); neither had systemic comorbidity (95.08%) nor problem of vision (84.92) with reported nonaddiction to alcohol (69.84%), smoking (74.75%), or chewing tobacco (85.57%). Formal training was received by three-fourths (77.38%), yet nearly all were consistently using seat belts and pursued front-seat passengers to use seat belts. The participants of our study admitted their avoidable risky behavior on roads during driving, namely used to talk in speaker mode (73.44%), calling (87.21%), and hearing music (49.84%), while minority (4.92%) confessed watching video and using Bluetooth headphone (11.80%); all these risky behaviors culminated in missing road signs by 71.80%. Conclusions: It appears from this study that we need to understand the sociodemographic, work environment, and personality details of the taxi drivers in the metropolitan cities. The following core competencies are addressed in this article: Interpersonal and communication skills, Patient care, Practice-based learning and improvement, and Systems-based practice.

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Context: Stress ulcer prophylaxis (SUP) has become the standard of care in the intensive care unit (ICU) but is often continued inappropriately at discharge. Aims: The primary aim was to evaluate the impact of granting clinical privileges to assess appropriate discontinuation of SUP in the ICU. Settings and Design: This study was a single-center, retrospective, observational study. Materials and Methods: Patients admitted to medical or surgical ICUs in January 2015 (pregroup) were compared to January 2016 (postgroup). Statistical Analysis Used: Continuous parametric data were analyzed with Student's t-test, continuous nonparametric data were analyzed with Mann–Whitney U-test, and dichotomous variables were analyzed with Fisher's exact method. Results: One hundred and sixty patients were included (80 per group). Over 50% of patients had documented home acid suppression therapy use (52.5% pregroup vs. 58.8% postgroup, P = 0.53) and approximately 30% had gastroesophageal reflux disease documented as a problem in their medical record (27.5% pregroup vs. 31.3% postgroup, P = 0.73). The rate of inappropriate continuation of acid suppression therapy was not different between groups (15.4% vs. 14.9%, P = 0.999). The major reason for appropriate continuation of acid suppressive therapy was the presence of a chronic condition that provided a reasonable indication for therapy (46.1% vs. 60.0%, P = 0.228). Conclusions: Overall we found no difference in continuation of SUP at ICU discharge, but this was confounded by a high rate of reported home acid suppression. Targets for education and improvement have been identified, especially the need for attention to documentation and medication reconciliation across the spectrum of patient care to allow for acid suppression therapy deprescribing. The following core competencies are addressed in this article: Patient care, Systems-based practice

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Paragonimiasis is a food-borne parasitic infection that commonly affects humans after ingestion of raw or undercooked crustaceans. The disease is caused by lung flukes of the genus Paragonimus, which is endemic to Southeast Asia. In this report, we describe two cases of paragonimiasis diagnosed in North American immigrants from Southeast Asia. The first patient presented with a 5-year history of hemoptysis. The second presented with a 3-week history of productive cough. Both patients were initially treated with antibiotics for presumed pneumonia. The inciting pathogen was not identified by blood, sputum, or stool analyses. Ultimately, surgical resection was required, leading to the diagnosis of paragonimiasis. In the United States and other nonendemic areas, the diagnosis of paragonimiasis is often delayed due to its rarity. Increased awareness and inclusion in differential diagnoses, especially in patients originating from endemic areas, may prevent diagnostic delay and associated morbidity. The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge, and Patient care.

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Fecal microbiota transplantation (FMT) re-emerged over the last decade, primarily in response to the escalating problem of health-care-associated Clostridium difficile (CD) infection (CDI). Increasing virulence and antibiotic resistance of CD prompted intensified efforts to broaden therapeutic options for this emerging health threat. It is well established that homeostasis of intestinal flora (or microbiota) is critical to human well-being. Introduction and misuse of various health-care related interventions, including antibiotics and gastric acid-reducing agents, contributed to the current state of crisis. Common therapeutic options for CDI include antibiotics, probiotics, and surgery. More recently, there has been as shift toward the utilization of FMT as a second-line option for severe/complicated CDI. The aim of this review is to provide health-care professionals with a concise summary of management options for CDI, with special focus on FMT and its indications, contraindications, and implementation experiences. The following core competencies are addressed in this article: Medical knowledge, Patient care and procedural skills, Systems-based practice.

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Background: Noncompliance with established prevention measures (seat belts/helmets) continues to be prevalent. Research has shown three primary methods of increasing compliance: legislation, education, and postcollision intervention. We hypothesized that after a motor vehicle collision (MVC) or motorcycle crash (MCC), there are higher rates of safety device noncompliance and this behavior will not align with the benefits of prevention. The study of these patterns will, therefore, provide insight for interventions and education. Materials and Methods: This was a prospective, survey-based study of 165 patients performed during June–July 2016 at a Level 1 trauma center. Inclusion criteria consisted of adults involved in either MCC or MVC. Study groups consisted of the MVC and MCC cohorts and those compliant and noncompliant with safety devices. Outcomes were analyzed by comparison of demographics, injury severity score, self-reported safety device use, and substance abuse. Answers given to the final open-ended question of the survey were sorted based on subject matter as it related to reasoning of safety device use. Results: Seat belt users (71.3%) were older (46 vs. 39 years, P = 0.038) and had fewer passengers (1.5 vs. 2.2, P = 0.012). Helmet wearers (30.6%) were more likely women (odds ratio: 9.6, P = 0.009) and less likely to have a positive blood alcohol concentration (BAC) (59.1% vs. 100.0%, P = 0.01). Primary reasons for seat belt use were habit, safety, and law, while primary reasons for helmet use were safety and habit. Overall noncompliant individuals from both MCC and MVC cohorts were more likely to have a positive BAC. Conclusions: Noncompliant patients' reasoning was contradictory to the known benefit of safety restraints. Primary prevention device use relies on establishing habit and perceived safety. Through the postcollision survey, we were able to gather more insight for lack of compliance and this behavioral pattern. Immediate intervention allowed for an opportunity in safety education. Benefit was noted in patients' opportunity for self-reflection and willingness to change behavior. The following core competencies are addressed in this article: Patient care, Practice-based learning and improvement.

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An 89-year-old Hispanic male patient presented to the emergency department with melena, decreased appetite, and weight loss. The physical exam revealed a firm, nontender, irregular nodule under the umbilicus. Computed tomography of abdomen showed a pancreatic head tumor with extensive metastatic disease in the abdominal organs and extension to the umbilicus. Umbilical nodule can sometimes be the only clinical manifestation of advanced metastatic disease, a thorough examination is required in patients that present with umbilical tumors. The following core competencies are addressed in this article: Patient care, Medical knowledge.

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Nontuberculous mycobacteria (NTM) or atypical mycobacteria are abundantly found in the environment. Extrapulmonary infections are most commonly caused by Mycobacterium chelonae, Mycobacterium fortuitum, Mycobacterium avium, and Mycobacterium kansasii. Risk factors for infection include both accidental/surgical trauma, all procedures involving implants, retained biomaterial. The isolation rate of NTM from India has been reported ranging from 0.5% to 8.6%. We report two culture-proven cases of infection caused by NTM. The present cases emphasize the importance of considering NTM in the differential diagnosis of nonhealing ulcers whether corneal or skin and soft tissue infections. The following core competencies are addressed in this article: Medical knowledge, Patient care.

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