Curēus
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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. ⋯ 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.
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Case Reports
Paradoxical Air Embolism Without Patent Foramen Ovale During Craniotomy in the Sitting Position.
Craniotomy in the sitting position entails risk for venous air embolism (VAE). A 50-year-old male underwent pineal region mass resection through a sitting position craniotomy. Intraoperative transesophageal echocardiography confirmed the absence of intracardiac shunt. ⋯ After repositioning to the supine position, significant crossover of air into the left heart was noted. Postoperatively, multiple small embolic strokes were noted. Patients who undergo craniotomy in the sitting position and are not found to have a patent foramen ovale (PFO) are not free of risk for paradoxical air embolism (PAE).
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Background Disproportionate change in the burden of diabetes mellitus across various subgroups has been reported in the United States. However, changing landscape of the prevalence and mortality of decompensated diabetes (diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)) remains indistinct across various age, gender, and racial groups of hospitalized diabetics. Methods The National Inpatient Sample (NIS) datasets (2007-2014) were sought to assess the prevalence and temporal trends in decompensated diabetes stratified by age, gender, and race and related in-hospital outcomes among the adult patients hospitalized with diabetes using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. ⋯ The rates of acute myocardial infarction (AMI) (10.4% vs. 4.8%; p<0.001), stroke (4.0% vs. 3.3%; p<0.001) and venous thromboembolism (3.5% vs. 2.6%; p<0.001) were substantially higher among diabetics with decompensation compared to those without. Conclusions There was an increasing trend in the prevalence of decompensated diabetes from 2007 to 2014, most remarkable among younger black male diabetics. The patients with decompensated diabetes suffered higher in-hospital mortality and rates of AMI, stroke and venous thromboembolism, there was no significant decline in the mortality between 2007 and 2014.
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Introduction Chronic migraine is particularly devastating. It affects school work, extracurricular activities, and quality of life, including relationships with other family members, and can also influence the mental health of both the migraineurs and family members. According to the International Classification of Headache Disorders, 3rd edition (ICHD-3), chronic migraine is defined as 15 or more headache days per month for greater than three months, where at least on eight days per month, there are features of migraine headache. Although botulinum toxin type A (BoNTA) has been proven effective for treating chronic migraine in adults, little literature exists about its use in children. Here, we present the treatment response in children with chronic migraines treated with BoNTA at our institutions Duke and State University of New York (SUNY) Upstate. Method A retrospective analysis of 30 adolescent migraineurs who met ICHD-3 criteria for chronic migraine were treated with BoNTA injection according to the standardized adult protocol. Descriptive statistics and paired t-tests were performed. ⋯ One patient developed nausea related to injections; all others tolerated it well, with no side effects. Discussion BoNTA injection was a safe and effective therapy for chronic migraine in our cohort of children recalcitrant to medical therapy. Further research with multi-centered, double-blinded, randomized, placebo-controlled trials is warranted to evaluate the long-term safety and efficacy in this population.
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We report the case of a 40-year-old patient with systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) overlap syndrome with pulmonary arterial hypertension (overlap-PAH) that was successfully treated with a combination of immunosuppressive therapy and the soluble guanylate cyclase stimulator riociguat. She was diagnosed with mixed connective tissue disease (MCTD) two years prior to admission. She was admitted to our hospital with dyspnea on exertion and progressive skin sclerosis. ⋯ We also started treatment with riociguat because we speculated she had a component of SSc-PAH and that immunosuppressive therapy alone may be insufficient. We chose riociguat because of its favorable treatment effect on SSc-PAH. Two months after treatment, her TRPG improved to 33 mmHg and the skin sclerosis improved dramatically, suggesting the efficacy of multi-drug treatment and the importance of early intervention.