Propylene glycol toxicity in an adolescent secondary to chronic cornstarch ingestion.

Propylene glycol (PG) is a diol (a double alcohol) that is commonly used as a food additive to preserve shelf life and enhance flavors, texture, and appearance. Although PG makes up only a small percentage of cornstarch, ingestion of large doses can cause lactic acidosis leading to hyperosmolarity, high anion gap metabolic acidosis (HAGMA), and a sepsis-like syndrome. A 17-year-old female presented to our emergency department (ED) with chronic chest pain, dyspnea, nausea, and vomiting. Laboratory testing showed an elevated anion gap of 18 mEq/L with no osmolar gap. Toxicology screening was negative. Twelve hours after ED arrival, she admitted to consuming one box of cornstarch daily for the past 6 months. She was admitted to the intensive care unit (ICU) with multisystem organ failure due to propylene glycol toxicity. After empiric treatment with fomepizole and continuous renal replacement therapy, her clinical status gradually improved. This case highlights the importance of obtaining a thorough dietary history in patients with suspected toxicities, especially when laboratory values demonstrate an unexplained HAGMA and/or lactic acidosis. Prompt recognition and therapeutic intervention with fomepizole, a potent inhibitor of alcohol dehydrogenase, is essential in reducing life-threatening sequelae following toxic alcohol ingestions.

Teaching Critical Thinking in Graduate Medical Education: Lessons Learned in Diagnostic Radiology.

The 2014 Institute of Medicine report, Graduate Medical Education that Meets the Nation's Health Needs, challenged the current graduate medical training process and encouraged new opportunities to redefine the fundamental skills and abilities of the physician workforce. This workforce should be skilled in critically evaluating the current systems to improve care delivery and health. To meet these goals, current challenges, motivations, and educational models at the medical school and graduate medical education levels related to formal training in nonclinical aspects of medicine, especially critical thinking, are reviewed. Our diagnostic radiology training program is presented as a "case study" to frame the review.

The presence of associated vascular findings on noncontrast enhanced CT of fractures in diabetics.

A 44-year-old female with diabetes and end-stage renal disease suffered a nondisplaced medial tibial plateau fracture after a ground-level fall. After open reduction and internal fixation, her popliteal artery and vein occluded at the level of the fracture. Review of the noncontrast computed tomography scan completed on initial arrival to the emergency department revealed a fracture in the calcified media of the popliteal artery at the level of the arterial occlusion. The propensity of different classes of tibial plateau fractures to be associated with soft-tissue and vascular injuries is examined in the context of different imaging modalities. The pathogenesis of arterial calcification and arterial dissection (including patients with renal disease and diabetics) is reviewed.