ACR Appropriateness Criteria® Abnormal Uterine Bleeding.

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Impact of a Mentorship Program on Medical Student Burnout.

BACKGROUND: Burnout can have negative consequences for providers' health and patient care. Mentorship has positive effects including stress mitigation. We sought to evaluate the impact of a mentorship program on burnout in fourth-year medical students during their 4-week emergency medicine subinternship. METHODS: This was a prospective, quasi-experimental, mixed-methods study at two institutions. We assessed burnout using the Maslach Burnout Inventory, comprising three subscales: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). We compared changes in burnout scores before and after implementation of a resident-student mentorship program. We compared categorical variables using risk ratios and continuous variables using Wilcoxon rank-sum test. To account for potential confounders, we performed multivariable analysis. Students and mentors completed an evaluative survey. We reported descriptive statistics and performed thematic qualitative analysis on free-response data. RESULTS: A total of 135 students (intervention = 51; control = 84) and 59 mentors participated. Intervention students demonstrated decreased EE and DP and increased PA scores, medians of -2 (-4 to 4), -1 (-3 to 2), and 1 (-1 to 4), respectively, compared to controls, median difference of 0 for all subscales. After adjusting for potential confounders, there was no significant difference in EE (mean difference = -0.2 [-0.5 to 0.2], p = 0.4) or DP scores (mean difference = -0.2 [-1.8 to 1.5], p = 0.9). There was a significant difference in PA scores (mean difference = 2.2 [0.1 to 4.3], p = 0.04). Most students felt the program positively impacted their rotation (39/48) and decreased stress (28/48). Students felt that the program provided career guidance and positively impacted their personal and professional development. The majority (34/37) of mentors enjoyed participating. Qualitative analysis revealed five major themes: relationship building, different perspective, knowledge sharing, personal fulfillment, and self-reflection. CONCLUSION: We found an increased sense of personal accomplishment after implementation of a mentorship program. Both mentors and mentees viewed the program positively and perceived multiple benefits.

Human Aldose Reductase Expression Prevents Atherosclerosis Regression in Diabetic Mice.

Guidelines to reduce cardiovascular risk in diabetes include aggressive LDL lowering, but benefits are attenuated compared with those in patients without diabetes. Consistent with this, we have reported in mice that hyperglycemia impaired atherosclerosis regression. Aldose reductase (AR) is thought to contribute to clinical complications of diabetes by directing glucose into pathways producing inflammatory metabolites. Mice have low levels of AR, thus raising them to human levels would be a more clinically relevant model to study changes in diabetes under atherosclerosis regression conditions. Donor aortae from Western diet-fed Ldlr-/- mice were transplanted into normolipidemic wild-type, Ins2Akita (Akita+/- , insulin deficient), human AR (hAR) transgenic, or Akita+/- /hAR mice. Akita+/- mice had impaired plaque regression as measured by changes in plaque size and the contents of CD68+ cells (macrophages), lipids, and collagen. Supporting synergy between hyperglycemia and hAR were the even more pronounced changes in these parameters in Akita+/- /hAR mice, which had atherosclerosis progression in spite of normolipidemia. Plaque CD68+ cells from the Akita+/- /hAR mice had increased oxidant stress and expression of inflammation-associated genes but decreased expression of anti-inflammatory genes. In summary, hAR expression amplifies impaired atherosclerosis regression in diabetic mice, likely by interfering with the expected reduction in plaque macrophage inflammation.

Ischemic Stroke: Advances in Diagnosis and Management.

Acute ischemic stroke carries the risk of morbidity and mortality. Since the advent of intravenous thrombolysis, there have been improvements in stroke care and functional outcomes. Studies of populations once excluded from thrombolysis have begun to elucidate candidates who might benefit and thus should be engaged in the process of shared decision-making. Imaging is evolving to better target the ischemic penumbra salvageable with prompt reperfusion. Availability and use of computed tomography angiography identifies large-vessel occlusions, and new-generation endovascular therapy devices are improving outcomes in these patients. With this progress in stroke treatment, risk stratification tools and shared decision-making are fundamental.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in the Pediatric Population: A Review.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe dermatologic reactions with mucocutaneous involvement that carry elevated mortality rates. They differ along a spectrum of severity based upon body surface area affected. These conditions, usually caused by a drug or infection, are believed to result from cell-mediated and often drug-specific cytotoxic reactions against keratinocytes, leading to widespread dermal-epidermal detachment. Studies attempting to identify potential curative therapies such as intravenous immune globulin (IVIG) and corticosteroids remain inconclusive. However, improved outcomes have been demonstrated by early withdrawal of offending medications, early transfer to an intensive care unit or burn unit, and aggressive supportive care. Due to the rare incidence of SJS and TEN, its recurrence among survivors hints at future vulnerability for these patients, and notorious offending medications should thus be avoided. This clinical review will highlight the diagnostic and therapeutic challenges posed by SJS and TEN, while emphasizing the need to maintain them high on the emergency medicine physician's differential. The review will also detail the supportive measures to take for preventing the rapid progression of mucocutaneous complications and subsequent sepsis-related mortality.

Cholesterol loading reprograms the microRNA-143/145-myocardin axis to convert aortic smooth muscle cells to a dysfunctional macrophage-like phenotype.

OBJECTIVE: We previously showed that cholesterol loading in vitro converts mouse aortic vascular smooth muscle cells (VSMC) from a contractile state to one resembling macrophages. In human and mouse atherosclerotic plaques, it has become appreciated that ≈40% of cells classified as macrophages by histological markers may be of VSMC origin. Therefore, we sought to gain insight into the molecular regulation of this clinically relevant process. APPROACH AND RESULTS: VSMC of mouse (or human) origin were incubated with cyclodextrin-cholesterol complexes for 72 hours, at which time the expression at the protein and mRNA levels of contractile-related proteins was reduced and of macrophage markers increased. Concurrent was downregulation of miR-143/145, which positively regulate the master VSMC differentiation transcription factor myocardin. Mechanisms were further probed in mouse VSMC. Maintaining the expression of myocardin or miR-143/145 prevented and reversed phenotypic changes caused by cholesterol loading. Reversal was also seen when cholesterol efflux was stimulated after loading. Notably, despite expression of macrophage markers, bioinformatic analyses showed that cholesterol-loaded cells remained closer to the VSMC state, consistent with impairment in classical macrophage functions of phagocytosis and efferocytosis. In apoE-deficient atherosclerotic plaques, cells positive for VSMC and macrophage markers were found lining the cholesterol-rich necrotic core. CONCLUSIONS: Cholesterol loading of VSMC converts them to a macrophage-appearing state by downregulating the miR-143/145-myocardin axis. Although these cells would be classified by immunohistochemistry as macrophages in human and mouse plaques, their transcriptome and functional properties imply that their contributions to atherogenesis would not be those of classical macrophages.