'Wargaming with the chiefs': A novel pre-mortem exercise to enhance communication and well-being among 'top gun' chief residents.

Pilots who complete the 'TOPGUN' program return to their squadrons as elite leaders and instructors. Physicians from all specialties who are selected to become Chief residents can also be viewed as 'Top Guns', as they are the 'cream of the crop'; having been chosen to be the leaders and role-models for all the other residents in their programs. Yet, unlike Top Gun pilots, Chief residents are arguably only minimally prepared for this new role. Wargaming involves generating every possible bad outcome and brainstorming contingencies for these possible outcomes. We developed an exercise for the incoming Chiefs (ICs) and outgoing Chiefs (OCs) in four specialties: Family Medicine, Internal Medicine, Neurosurgery, and Neurology. Following this exercise, 100% of the Chiefs in all four programs indicated that this activity was beneficial and the majority agreed that wargaming improved communication and their own feelings of well-being. Based on our trainees' feedback, it appears that wargaming is a simple, fun, and highly-interactive exercise which increases perceived control among ICs and allows OCs the chance to reflect and share their knowledge and experience with the new Chiefs. This activity also seems to enhance communication and feelings of well-being among both incoming and outgoing Chief residents.

The illness experience of an undocumented immigrant in the USA.

Approximately 11 million people living and working in the USA do so without documentation. This group represents a disenfranchised minority with adverse experiences and unique comorbidities that faces significant obstacles to receiving healthcare, including fear of deportation, language barriers, financial barriers and difficulty navigating an inconsistent and fragmented system. Healthcare is therefore often sought once symptoms have become critical, which can lead to more severe disease processes and multiple new diagnoses at presentation even in previously healthy patients. Here we present the case of a previously healthy 32-year-old undocumented immigrant who presented to a South Florida hospital with abdominal pain, diarrhoea and leg pain. He was diagnosed with both diabetes mellitus and chronic myelogenous leukaemia after a prolonged 20-day hospital stay. Culturally sensitive providers and dedicated staff play a major role in connecting patients to outpatient care after an acute illness, which most often occurs at charity clinics.

Diabetic Ketoacidosis in Patients with Type 2 Diabetes on Sodium-Glucose Cotransporter-2 Inhibitors - A Case Series.

BACKGROUND: Diabetic ketoacidosis (DKA) is a serious complication of diabetes seen commonly in autoimmune Type 1 diabetes mellitus (DM), however patients with Type 2 diabetes are also at risk. Diabetic ketoacidosis may be precipitated by the catabolic stress of acute illness such as trauma, surgery, or infections. Recent studies have suggested that sodium-glucose cotransporter-2 (SGLT-2) inhibitors precipitate DKA in Type 2 diabetes. We present a case series of four patients on SGLT-2 inhibitors who presented with DKA. METHODS: Medical records were reviewed and patients who were admitted with diabetic ketoacidosis in the last one year at our institute were identified. The charts of such patients were reviewed and we were able to identify 4 patients who were admitted with DKA and were on SGLT-2 inhibitors at the time of admission for the management of their diabetes. RESULTS: The age group of the four patients was between 45-65 years. Interestingly, all four patients were female. The admission blood glucose levels of these patients ranged from 203 to 400(mg/dl). The pH at the time of admission was in the acidotic range with anion gap ranging from 19 to 24. Two of these four patients had symptoms of a localized infection at the time of admission, which was confirmed by laboratory and radiological evaluation. Three of these patients required management in the intensive care unit. CONCLUSION: Ketoacidosis is a rare but serious side effect of SGLT2 inhibitors. It is being increasingly reported as these drugs are now commonly being prescribed in the primary care setting. Awareness that DKA can occur in the setting of relative euglycemia is critical to recognize this life-threatening complication of diabetes. More research is needed to better understand the underlying pathophysiology and precipitating factors leading to ketoacidosis in SGLT-2 inhibitor treated patients.

Organ donation by a prisoner: legal and ethical considerations.

The supply of available organs for donation is limited. In this article we describe the legal and ethical principles surrounding donation of organs from a prisoner.

The elite code grey team: a new model for residency preparedness and training in advance of a disaster.

Hurricane Katrina and the resulting levee failures decimated the New Orleans landscape, trapping physicians inside hospital facilities for up to 5 days. With over 2000 people trapped in the 3 primary teaching hospitals, there were only 3 fatalities. Yet despite the lack of adverse events, the experience revealed that graduate medical education is woefully underprepared to deal with disaster. As call schedules obviously did not anticipate the disaster, the assignment of physicians to these shifts was random, without regard to the ability to withstand that stress and the conditions. The group of physicians that was assigned was a heterogeneous mix of personalities, experience levels, and psychological fortitude. None of the physicians had been formally trained in the core principles of disaster management. This article reviews an innovative approach to disaster management, drawing upon the expertise of law enforcement, the airline industry, and on-going physician development programs in disaster medicine.

Genetic clamping of renin gene expression induces hypertension and elevation of intrarenal Ang II levels of graded severity in Cyp1a1-Ren2 transgenic rats.

INTRODUCTION: Transgenic rats with inducible angiotensin II (Ang II)-dependent hypertension (strain name: TGR[Cyp1a1-Ren2]) were generated by inserting the mouse Ren2 renin gene, fused to the cytochrome P450 1a1 (Cyp1a1) promoter, into the genome of the rat. The present study was performed to characterise the changes in plasma and kidney tissue Ang II levels and in renal haemodynamic function in Cyp1a1-Ren2 rats following induction of either slowly developing or malignant hypertension in these transgenic rats. MATERIALS AND METHODS: Arterial blood pressure (BP) and renal haemodynamics and excretory function were measured in pentobarbital sodium-anaesthetised Cyp1a1- Ren2 rats fed a normal diet containing either a low dose (0.15%, w/w for 1415 days) or high dose (0.3%, w/w for 1112 days) of the aryl hydrocarbon indole-3-carbinol (I3C) to induce slowly developing and malignant hypertension, respectively. In parallel experiments, arterial blood samples and kidneys were harvested for measurement of Ang II levels by radioimmunoassay. RESULTS: Dietary I3C increased plasma renin activity (PRA), plasma Ang II levels, and arterial BP in a dose-dependent manner. Induction of different fixed levels of renin gene expression and PRA produced hypertensive phenotypes of varying severity with rats developing either mild or malignant forms of hypertensive disease. Administration of I3C, at a dose of 0.15% (w/w), induced a slowly developing form of hypertension whereas administration of a higher dose (0.3%) induced a more rapidly developing hypertension and the clinical manifestations of malignant hypertension including severe weight loss. Both hypertensive phenotypes were characterised by reduced renal plasma flow, increased filtration fraction, elevated PRA, and increased plasma and intrarenal Ang II levels. These I3C-induced changes in renal haemodynamics, PRA and kidney Ang II levels were more pronounced in Cyp1a1-Ren2 rats with malignant hypertension. Chronic administration of the AT1-receptor antagonist, hypertension, the associated changes in renal haemodynamics, and the augmentation of intrarenal Ang II levels. CONCLUSIONS: Activation of AT1-receptors by Ang II generated as a consequence of induction of the Cyp1a1-Ren2 transgene mediates the increased arterial pressure and the associated reduction of renal haemodynamics and enhancement of intrarenal Ang II levels in hypertensive Cyp1a1-Ren2 transgenic rats.