SIMPLE procedures: Survey of Internal Medicine Providers' Limitations and Experiences with procedures and medical procedure services.

BACKGROUND: In response to a decline in bedside procedures performed by hospitalists, some hospital medicine groups have created medical procedure services (MPSs) concentrating procedures under the expertise of trained hospitalist-proceduralists. OBJECTIVES: To characterize the structure, breadth, and heterogeneity of academic medical center MPSs, as well as compare the procedural landscape for groups with and without an MPS. METHODS: The Survey of Internal Medicine Providers' Limitations and Experiences with Procedures and MPSs, is a cross-sectional study, conducted in the United States and Canada through a web-based survey administered from October 2022 to March 2023. We used convenience and snowball sampling to identify eligible study participants. The survey explored presence of MPS, procedure volumes, patient safety, and educational practices. For MPSs, we explored onboarding, staffing, skill maintenancy, funding, and barriers to growth. RESULTS: Forty instututions (response rate 97.5%), represented by members of the Procedural Research and Innovation for Medical Educators (PRIME) consortum participated in the survey. MPSs were found in 75% of the surveyed institutions. Most MPSs (97%) involved trainees and were staffed by internists (100%) who often had additional clinical duties (70%). The majority (83%) of MPSs used checklists and procedural safety guidelines, but only 53% had a standardized process for tracking complications. There was significant variability in determining procedural competency and supervising trainees. Groups with an MPS reported higher procedure volume compared to those without. CONCLUSIONS: MPSs were highly prevalent among the participating instutitions, offered a broad array of bedside procedures, and often included trainees. There was a high variability in funding models, procedure volumes, patient safety practices, and skill maintenance requirements.

ACR Appropriateness Criteria® Workup of Pleural Effusion or Pleural Disease.

Pleural effusions are categorized as transudative or exudative, with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders. This document summarizes appropriateness guidelines for imaging in four common clinical scenarios in patients with known or suspected pleural effusion or pleural disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Staging and Follow-Up of Esophageal Cancer.

This document provides recommendations regarding the role of imaging in the staging and follow-up of esophageal cancer. For initial clinical staging, locoregional extent and nodal disease are typically assessed with esophagogastroduodenoscopy and esophageal ultrasound. FDG-PET/CT or CT of the chest and abdomen is usually appropriate for use in initial clinical staging as they provide additional information regarding distant nodal and metastatic disease. The detection of metastatic disease is critical in the initial evaluation of patients with esophageal cancer because it will direct patients to a treatment pathway centered on palliative radiation rather than surgery. For imaging during treatment, particularly neoadjuvant chemotherapy, FDG-PET/CT is usually appropriate, because some studies have found that it can provide information regarding primary lesion response, but more importantly it can be used to detect metastases that have developed since the induction of treatment. For patients who have completed treatment, FDG-PET/CT or CT of the chest and abdomen is usually appropriate for evaluating the presence and extent of metastases in patients with no suspected or known recurrence and in those with a suspected or known recurrence. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Suspected Pulmonary Hypertension: 2022 Update.

Pulmonary hypertension may be idiopathic or related to a large variety of diseases. Various imaging examinations may be helpful in diagnosing and determining the etiology of pulmonary hypertension. Imaging examinations discussed in this document include chest radiography, ultrasound echocardiography, ventilation/perfusion scintigraphy, CT, MRI, right heart catheterization, and pulmonary angiography. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

An abdominal skin lesion: to lump or split? a case presentation.

Syphilis has many atypical morphologies which can present a diagnostic challenge, especially in patients with HIV/AIDS who may have multiple concurrent conditions. We describe a 41-year-old man with recently diagnosed HIV who was admitted for acute right vision loss and a diffuse rash with involvement of the palms and soles. He received diagnoses of secondary syphilis and Kaposi sarcoma in the setting of AIDS. Examination revealed an unusual dark brown-to-purple umbilicated papule with a necrotic center on the abdomen, raising a diagnostic dilemma. Skin biopsy showed secondary syphilis, despite the concurrent diagnosis of Kaposi sarcoma. The patient was treated with antibiotic and antiretroviral therapy and symptoms resolved. This case aims to share the clinical reasoning behind diagnosing a patient with HIV/AIDS with multiple concurrent conditions and to raise awareness of the many atypical cutaneous manifestations of secondary syphilis.

A Covid-19 Patient with Complement-Mediated Coagulopathy and Severe Thrombosis.

We report a patient with severe Covid-19-associated coagulopathy and type 2 diabetes mellitus who tested positive for antiphospholipid antibodies (aPL). Analysis of skin specimens suggested direct SARS-CoV-2 viral-induced and complement-mediated vascular injury and thrombosis, consistent with prior reports. Serial aPL testing demonstrated high levels of anticardiolipin antibodies (aCL) that declined to insignificant levels over a period of 5 weeks. SARS-CoV-2 RNA was detected in nasopharyngeal swab specimens on serial assays performed over the same 5-week period, though it was not detected thereafter. We hypothesize that SARS-CoV-2 viral-induced aPL contributed to severe Covid-19-associated coagulopathy in this patient.

Association Between Methamphetamine Use and Psychiatric Hospitalization, Chemical Restraint, and Emergency Department Length of Stay.

OBJECTIVES: Methamphetamine intoxication is an increasing cause of emergency department (ED) visits in the United States, particularly in the west. In San Francisco, California, 47% of patients visiting psychiatric emergency services are intoxicated with methamphetamine. Such patients often visit the ED due to acute psychiatric symptoms, yet ED-based research investigating the outcomes and resource utilization of these visits is limited. METHODS: We examined a retrospective cohort of ED patients requiring ED-based psychiatric consultation from June 2017 to July 2018. We evaluated the association between methamphetamine visits and need for chemical restraint, psychiatric hospitalization, and length of stay (LOS). RESULTS: We identified 2,087 ED visits with psychiatric consults. Based on urine toxicology results and discharge diagnosis, 403 visits involved methamphetamine with or without other drugs, 480 involved other drugs without methamphetamine, and 1,204 had no evidence of drug use. Methamphetamine visits were associated with increased odds of chemical restraint compared to visits without drug use (adjusted odds ratio [AOR] = 3.2, 95% CI = 2.1 to 5.2, p < 0.001), but not other drug visits (AOR = 1.2, 95% CI = 0.8 to 1.9, p = 0.4). Methamphetamine visits had lower odds of psychiatric hospitalization than other drug visits (AOR = 0.62, 95% CI = 0.41 to 0.95, p = 0.03) and longer adjusted LOS than visits without drug use (+4.3 hours, 95% CI = 4.1 to 8.3 hours, p < 0.001) but not other drug visits (+1.5 hours, 95% CI = -0.6 to 3.7 hours, p = 0.2). CONCLUSIONS: Methamphetamine ED visits were associated with increased odds of needing chemical restraint and of an increased ED LOS but not with psychiatric inpatient admission. These results indicate an opportunity to improve the efficiency of ED care for these patients.

SEVERE INSULIN RESISTANCE WITH DIABETIC KETOACIDOSIS AFTER BRENTUXIMAB TREATMENT.

OBJECTIVE: To increase awareness of unusual inflammatory and other responses including severe insulin resistance (IR) associated with the use of targeted immunotherapies such as brentuximab. METHODS: We report the case of a man without any previous diagnosis of diabetes who developed diabetic ketoacidosis complicated by severe IR (unresponsive to >600 units of intravenous insulin per hour) after receiving brentuximab for Hodgkin lymphoma. RESULTS: Autoantibodies to the insulin receptor were not detected in the patient's serum, thus excluding a diagnosis of type B IR. CONCLUSION: We hypothesize that brentuximab administration led to a rare reaction leading to systemic cytokine release with extreme IR in our patient.

Severe H1N1-Associated acute respiratory distress syndrome: A case series.

BACKGROUND: Acute respiratory distress syndrome resulting from novel influenza A virus (H1N1) infection remains uncommon. METHODS: We describe the clinical profiles of adult patients with acute respiratory distress syndrome due to microbiologically confirmed H1N1 admitted to a medical intensive care unit in San Francisco, California over a 2-month period. RESULTS: Between June 1 and July 31, 2009, 7 patients (age range: 25-66 years; 4 patients under the age of 40 years; 6 male; 1 pregnant) were diagnosed with H1N1, with 5 of 6 (83%) having initial false-negative rapid testing. All developed respiratory failure complicated by acute respiratory distress syndrome, with 4 additionally developing multiorgan dysfunction. All were managed with a lung protective ventilator strategy (average number of days on the ventilator: 16), and 4 patients also required additional rescue therapies for refractory hypoxemia, including very high positive end-expiratory pressure, inhaled epoprostenol, recruitment maneuvers, and prone positioning. Despite these measures, 3 patients (43%) ultimately died. CONCLUSIONS: Clinicians should be vigilant for the potential of H1N1 infection to progress to severe acute respiratory distress syndrome in a variety of patient demographics, including younger patients without baseline cardiopulmonary disease. A high degree of suspicion is critical, especially with the relative insensitivity of rapid testing, and should prompt empiric antiviral therapy.

Spectrum of adverse events after generic HAART in southern Indian HIV-infected patients.

To determine the incidence of clinically significant adverse events after long-term, fixed-dose, generic highly active antiretroviral therapy (HAART) use among HIV-infected individuals in South India, we examined the experiences of 3154 HIV-infected individuals who received a minimum of 3 months of generic HAART between February 1996 and December 2006 at a tertiary HIV care referral center in South India. The most common regimens were 3TC + d4T + nevirapine (NVP) (54.8%), zidovudine (AZT) + 3TC + NVP (14.5%), 3TC + d4T + efavirenz (EFV) (20.1%), and AZT + 3TC + EFV (5.4%). The most common adverse events and median CD4 at time of event were rash (15.2%; CD4, 285 cells/microL) and peripheral neuropathy (9.0% and 348 cells/microL). Clinically significant anemia (hemoglobin <7 g/dL) was observed in 5.4% of patients (CD4, 165 cells/microL) and hepatitis (clinical jaundice with alanine aminotransferase > 5 times upper limits of normal) in 3.5% of patients (CD4, 260 cells/microL). Women were significantly more likely to experience lactic acidosis, while men were significantly more likely to experience immune reconstitution syndrome (p < 0.05). Among the patients with 1 year of follow-up, NVP therapy was significantly associated with developing rash and d4T therapy with developing peripheral neuropathy (p < 0.05). Anemia and hepatitis often occur within 12 weeks of initiating generic HAART. Frequent and early monitoring for these toxicities is warranted in developing countries where generic HAART is increasingly available.

Antiretroviral medication considerations for individuals coinfected with HIV and hepatitis C virus.

There is great need to treat HIV/hepatitis C virus (HCV)-coinfected individuals with both antiretroviral and anti-HCV pharmacotherapy. However, treatment for HIV may lead to hepatotoxicity, and there are potential interactions and synergistic effects between antiretrovirals and anti-HCV medications. The ideal antiretroviral therapy options for coinfected patients, in the setting of anti-HCV treatment, are unclear and present important challenges to clinicians. We review the current data on the use of antiretrovirals in HIV/HCV-coinfected patients and offer evidence-based recommendations on optimal selection and dosing of antiretroviral agents for this population.