Broken and forgotten: A case of unintentionally retained foreign object.

Central venous catheter have become ubiquitous with greater than 15 million catheter days/year in the intensive care setting alone. However, the procedure carries with it several immediate and other delayed complications that can result in significant morbidity, mortality, and increased healthcare cost. We report a rare case of significantly delayed complications associated with intravascular loss of guide wire during central venous catheter placement and its impact on patient's long term management. The case highlights not only the importance of proper technique and safety precaution in performing an increasingly common procedure, but also the need for timely identification and rectification of medical errors, especially in the context of improved physician-patient communication.

Prevalence of Intestinal Parasites in a Low-Income Texas Community.

Strongyloidiasis affects an estimated hundreds of millions of people worldwide, with infection possibly persisting for life without appropriate therapy because of the helminth's unique autoinfection cycle. Like other soil-transmitted helminths, because of the environmental conditions required for the life cycle of Strongyloides stercoralis, this parasite is endemic to tropical, subtropical, and temperate countries and areas with inadequate sanitation infrastructure. Given continued poverty and that nearly one in five American homes are lacking proper sanitation systems, many U.S. regions are at risk for intestinal parasites. A central Texas community was chosen as the study site, given previous reports of widespread sanitation failure, degree of poverty, and community willingness to participate. A total of 92 households were surveyed and residents tested for nine intestinal parasites using a multi-parallel quantitative real-time polymerase chain reaction and ELISA serology. From 43 stool samples, 27 (62.8%) tested positive for Blastocystis spp. and one (2.3%) for Giardia lamblia. From 97 serum samples, Strongyloides serology detected 16 (16.5%) positive individuals. These high rates of heterokont and helminthic laboratory findings in a peri-urban central Texas community suggest several key policy implications, including that strongyloidiasis should be added to the Texas notifiable conditions list, that clinical suspicion for this infection should be heightened in the region, and that residents without access to functioning and sustainable sanitation infrastructure should be provided that access as a basic human right and to promote public health.

Correction to: Impact of antibiotic therapy on the development and response to treatment of immune checkpoint inhibitor-mediated diarrhea and colitis.

Following publication of the original article [1], the authors have reported that an author's name has been incorrectly spelled: the correct given name is Anne-Marie (instead of Anne-Maria P) and family name is Chaftari.

Impact of antibiotic therapy on the development and response to treatment of immune checkpoint inhibitor-mediated diarrhea and colitis.

BACKGROUND: The gut microbiome impacts the efficacy of immune checkpoint inhibitor (ICI) therapy and the development of ICI-mediated diarrhea and/or colitis (IMDC). Antibiotic therapy,especially that with anaerobic activity, has profound effects on the gut microbiome. Therefore, we sought to assess the effect of antibiotics on the development of IMDC. METHODS: Patients who received ICI therapy from January 2016 to January 2018 were examined retrospectively. A Cox regression model was used to assess factors associated with overall survival. RESULTS: A total of 826 patients were included. Of these patients, 51.6% received inhibitors of programmed cell death protein-1 or its ligand, 32.0% received inhibitors of cytotoxic T-lymphocyte-associated antigen-4, and 16.5% received a combination of the two. IMDC occurred in 52.5% of the patients after a median of 8 weeks. Overall, 569 patients (68.9%) received antibiotic therapy. Antibiotic use at any time was associated with reduced IMDC occurrence and recurrence rates but also with frequent hospitalization and intensive care unit admission for IMDC as well as increased IMDC severity. Compared with patients who received antibiotic therapy only before ICI therapy initiation, those receiving it after ICI had a higher IMDC rate and more often needed immunosuppressive therapy and hospitalization for IMDC. Antibiotics with anaerobic activity were included in 51% of the antibiotic therapy regimens and were associated with increased immunosuppressant use, hospitalization, intensive care unit admission for IMDC, and severe IMDC grades. Forty-one patients received empiric prophylactic antibiotic therapy at IMDC onset. These patients more often needed immunosuppressive therapy, intravenous steroids, and infliximab/vedolizumab; had more frequent and longer hospitalization for IMDC and higher IMDC grades; and more frequently had IMDC recurrence than did patients who did not receive antibiotic therapy at the time of IMDC symptom onset. CONCLUSIONS: Whereas antibiotic therapy appeared to be protective against IMDC onset, use of antibiotics, especially those with anaerobic activity, after ICI therapy was associated with increased risk of severe IMDC.

Which Student Characteristics Are Most Important in Determining Clinical Honors in Clerkships? A Teaching Ward Attending Perspective.

PURPOSE: To explore faculty perspectives on which characteristics of high-performing clerkship students are most important when determining an honors or top grade designation for clinical performance. METHOD: In 2016-2017, the authors surveyed faculty (teaching ward attendings) for internal medicine clerkships and 1 pediatrics clerkship in inpatient settings at 5 U.S. academic medical centers. Survey items were framed around competencies, 24 student characteristics, and attitudes toward evaluation. Factor analysis examined constructs defining high-performing students. RESULTS: Of 516 faculty invited, 319 (62%) responded. The top 5 characteristics as rated by respondents were taking ownership, clinical reasoning, curiosity, dependability, and high ethical standards (in descending order). Twenty-one characteristics fit into 3 factors (Cronbach alpha, 0.81-0.87). Clinical reasoning did not fit into a factor. Factor 1 was the most important (mean rating, 8.7/10 [95% confidence interval (CI), 8.6-8.8]). It included professionalism components (ownership, curiosity, dependability, high ethical standards), presentation and interviewing skills, seeking feedback, and documentation. Factor 2 (mean, 7.9 [95% CI, 7.7-8.0]) included aspects of teamwork and communication, such as positive attitude and comments from others. Factor 3 (mean, 7.6 [95% CI, 7.4-7.7]) addressed systems-based thinking, including patient safety and care transitions. CONCLUSIONS: Professionalism components, clinical reasoning, and curiosity were among the most important characteristics distinguishing high-performing clerkship students. These may represent behaviors that are highly valued, observable, and relevant to training stage. Improved definition of the characteristics associated with clinical honors would assist students, faculty, and residency program directors when interpreting clinical performance within core clerkships.

Identifying High-Performing Students in Inpatient Clerkships: A Qualitative Study.

OBJECTIVES: Examine fundamental behaviors and characteristics that attending physicians in inpatient settings utilize to identify high-performing clerkship students. METHODS: We employed written comment data from a cross-sectional survey of Internal Medicine and Pediatrics attending physicians at a single academic medical center in the southern USA. Free-text responses regarding factors that faculty consider when assigning honors grades were analyzed by four trained researchers (interrater agreement 0.87) using conventional content analysis to identify themes. RESULTS: Seventy-nine of 141 (56%) attending physicians who were surveyed provided 90 comments.Four major theme areas for recognizing higher performing clerkship students were identified: Taking Ownership of Patient Care (35%), Medical Knowledge and Clinical Reasoning (20%), Team Orientation (15%), and Awareness of Opportunities for Growth and Progress (13%). CONCLUSION: Internal Medicine and Pediatric attending physicians identified characteristics that contributed to four themes in the determination of a high-performing medical student. These findings are particularly salient, as they highlight that commitment to patients, application of clinical knowledge and skills, teamwork, and awareness of growth and progress are valued by attending physicians for identifying top performing students in inpatient settings.

National Characteristics of Emergency Medical Services Responses for Older Adults in the United States.

OBJECTIVE: Older adults, those aged 65 and older, frequently require emergency care. However, only limited national data describe the Emergency Medical Services (EMS) care provided to older adults. We sought to determine the characteristics of EMS care provided to older adults in the United States. METHODS: We used data from the 2014 National Emergency Medical Services Information System (NEMSIS), encompassing EMS response data from 46 States and territories. We excluded EMS responses for children <18 years, interfacility transports, intercepts, non-emergency medical transports, and standby responses. We defined older adults as age ≥65 years. We compared patient demographics (age, sex, race, primary payer), response characteristics (dispatch time, location type, time intervals), and clinical course (clinical impression, injury, procedures, medications) between older and younger adult EMS emergency 9-1-1 responses. RESULTS: During the study period there were 20,212,245 EMS emergency responses. Among the 16,116,219 adult EMS responses, there were 6,569,064 (40.76%) older and 9,547,155 (59.24%) younger adults. Older EMS patients were more likely to be white and the EMS incident to be located in healthcare facilities (clinic, hospital, nursing home). Compared with younger patients, older EMS patients were more likely to present with syncope (5.68% vs. 3.40%; OR 1.71; CI: 1.71-1.72), cardiac arrest/rhythm disturbance (3.27% vs. 1.69%; OR 1.97; CI: 1.96-1.98), stroke (2.18% vs. 0.74%; OR 2.99; CI: 2.96-3.02) and shock (0.77% vs. 0.38%; OR 2.02; CI: 2.00-2.04). Common EMS interventions performed on older persons included intravenous access (32.02%), 12-lead ECG (14.37%), CPR (0.87%), and intubation (2.00%). The most common EMS drugs administered to older persons included epinephrine, atropine, furosemide, amiodarone, and albuterol or ipratropium. CONCLUSION: One of every three U.S. EMS emergency responses involves older adults. EMS personnel must be prepared to care for the older patient.