Enhancing point-of-care ultrasound (POCUS) utilization in primary care: A thyroid POCUS training course for internal medicine residents.

BACKGROUND: POCUS is valuable in primary care, yet outpatient-specific point-of-care ultrasound (POCUS) curriculum integration into internal medicine (IM) residency is limited. We addressed this gap by developing a thyroid POCUS workshop for IM residents. AIM: Develop and implement an educational curriculum to integrate thyroid POCUS into an IM residency program and evaluate the impact on resident knowledge, perceived skills, and attitudes. SETTING: The study was conducted in a resident primary care clinic at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Residency Program in Internal Medicine at North Shore University Hospital and Long Island Jewish Medical Center. PARTICIPANTS: All 108 IM residents (PGY1-3) in one program participated in the study during their ambulatory clinic block. PROGRAM DESCRIPTION: Residents participated in a 1-hour workshop involving a didactic session and two breakout groups: one for hands-on practice and another for case-based discussions with image review. PROGRAM EVALUATION: Residents completed pre- and post-session surveys assessing knowledge, perceived skills, and attitudes toward thyroid POCUS. These data showed statistically significant increases in all assessed areas. DISCUSSION: Integrating thyroid POCUS into an IM residency curriculum significantly improved resident knowledge, attitudes, and perceived skills related to these exams. Residents valued this learning experience and expressed intentions to incorporate it into their future practice.

A system approach to improving guideline-directed therapy for cardio-renal-metabolic conditions: The "beyond diabetes" initiative.

Objective: Despite demonstrating improvements in cardiovascular disease, kidney disease, and survival outcomes, guideline-directed antihyperglycemic medications such as sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like-peptide-1 receptor agonists (GLP1-RA), are underutilized. Many obstacles constrain their use including lack of systematic provider and patient education, concern for medication side effects, and patient affordability. Methods: We designed a multimodality, systems-based approach to address these challenges with the goal of increasing medication utilization across the largest healthcare system in New York State. This multispecialty collaborative included provider and patient education, an electronic health record-enabled platform to identify eligible patients, and access to pharmacists for medication guidance and addressing insurance coverage barriers. Surveys were administered following grand rounds lectures and knowledge-based questionnaires were given before and after case-based sessions for housestaff, with results analyzed using a two-sided Student's t-test. Rates of first prescriptions of SGLT2i/GLP1-RA in combined and individual analyses were compared between the pre- and post-education periods (6 months prior to 3/31/2021 and 6 months post 8/19/2021), and the change in prescriptions per 100 eligible-visits was assessed using the incidence density approach. Results: Among grand rounds participants, 69.3% of respondents said they would make changes to their clinical practice. Knowledge increased by 14.7% (p-value <0.001) among housestaff following case-based sessions. An increase in SGLT2i/GLP1-RA prescribing was noted for eligible patients among internal medicine, cardiology, nephrology, and endocrinology providers, from 11.9 per 100 eligible visits in the pre-education period to 14.8 in the post-education period (absolute increase 2.9 [24.4%], incidence risk ratio 1.24 [95% CI 1.18-1.31]; p-value <0.001). Increases in prescribing rates were also seen among individual medical specialties. Conclusions: Our "Beyond Diabetes" initiative showed an improvement in provider knowledge-base and was associated with a modest, but statistically significant increase in the use of SGLT2i and GLP1-RA throughout our healthcare system.

The Challenge of Intermediate-Risk Pulmonary Embolism.

BACKGROUND: Intermediate-risk pulmonary embolism is a common disease that is associated with significant morbidity and mortality; however, a standardized treatment protocol is not well-established. AREAS OF UNCERTAINTY: Treatments available for intermediate-risk pulmonary embolisms include anticoagulation, systemic thrombolytics, catheter-directed therapies, surgical embolectomy, and extracorporeal membrane oxygenation. Despite these options, there is no clear consensus on the optimal indication and timing of these interventions. THERAPEUTIC ADVANCES: Anticoagulation remains the cornerstone of treatment for pulmonary embolism; however, over the past 2 decades, there have been advances in the safety and efficacy of catheter-directed therapies. For massive pulmonary embolism, systemic thrombolytics and, sometimes, surgical thrombectomy are considered first-line treatments. Patients with intermediate-risk pulmonary embolism are at high risk of clinical deterioration; however, it is unclear whether anticoagulation alone is sufficient. The optimal treatment of intermediate-risk pulmonary embolism in the setting of hemodynamic stability with right heart strain present is not well-defined. Therapies such as catheter-directed thrombolysis and suction thrombectomy are being investigated given their potential to offload right ventricular strain. Several studies have recently evaluated catheter-directed thrombolysis and embolectomies and demonstrated the efficacy and safety of these interventions. Here, we review the literature on the management of intermediate-risk pulmonary embolisms and the evidence behind those interventions. CONCLUSIONS: There are many treatments available in the management of intermediate-risk pulmonary embolism. Although the current literature does not favor 1 treatment as superior, multiple studies have shown growing data to support catheter-directed therapies as potential options for these patients. Multidisciplinary pulmonary embolism response teams remain a key feature in improving the selection of advanced therapies and optimization of care.

Implementation of Novel Lipid Therapies in a Refractory Heterozygous Familial Hypercholesterolemia Patient With Atherosclerotic Disease.

Compound heterozygous familial hypercholesterolemia patients are phenotypically similar to homozygous familial hypercholesterolemia patients, present with significant elevations of low-density lipoprotein cholesterol, and are at risk of cardiovascular disease. Although new treatment options are emerging, the stepwise approach to the use of different therapies has not been well described. (Level of Difficulty: Intermediate.).

A Novel Calcium Channel Blocker: Etripamil: What is the Future of Intranasal Drug Delivery in the Treatment of Cardiac Arrhythmias?

Symptomatic paroxysmal cardiac arrhythmias are common cardiac conditions that lead to a decreased quality of life, increased healthcare costs, and significant morbidity. Many cardiac arrhythmias increase in frequency with age, and as the elderly population continues to increase, so will the incidence and prevalence of cardiac arrhythmias. The long-term treatment options for patients with paroxysmal arrhythmias include ablation procedures and daily oral antiarrhythmics. Acute management entails vagal maneuvers, intravenous antiarrhythmics, and synchronized cardioversion. However, there are limited treatment options for patients with less frequent and less severe arrhythmias, ablation refractory disease, or who are poor candidates for ablative procedures, For abortive therapy, oral anti-arrhythmic medications are ineffective due to their slow onset of action and intravenous medications require treatment at an acute care facility, which is both costly and stressful to the patient. Etripamil is a novel intranasal non-dihydropyridine calcium channel blocker that has begun phase III clinical trials for the treatment of paroxysmal supraventricular tachycardias. Due to its intranasal mode of delivery, etripamil has a rapid onset of action, and could feasibly be administered by the patient themselves. Clinical phase II trials of etripamil in moderate to high doses demonstrated efficacy comparable to the standard of care, and took an average of 3 minutes from drug administration to conversion to sinus rhythm. In this article, we have conducted an extensive literature review of intranasal drug delivery, calcium channel blockers, and etripamil, to discuss the future possibilities of using this new medication.

Discovery of Small-Molecule Antibiotics against a Unique tRNA-Mediated Regulation of Transcription in Gram-Positive Bacteria.

The emergence of multidrug-resistant bacteria necessitates the identification of unique targets of intervention and compounds that inhibit their function. Gram-positive bacteria use a well-conserved tRNA-responsive transcriptional regulatory element in mRNAs, known as the T-box, to regulate the transcription of multiple operons that control amino acid metabolism. T-box regulatory elements are found only in the 5'-untranslated region (UTR) of mRNAs of Gram-positive bacteria, not Gram-negative bacteria or the human host. Using the structure of the 5'UTR sequence of the Bacillus subtilis tyrosyl-tRNA synthetase mRNA T-box as a model, in silico docking of 305 000 small compounds initially yielded 700 as potential binders that could inhibit the binding of the tRNA ligand. A single family of compounds inhibited the growth of Gram-positive bacteria, but not Gram-negative bacteria, including drug-resistant clinical isolates at minimum inhibitory concentrations (MIC 16-64 µg mL-1 ). Resistance developed at an extremely low mutational frequency (1.21×10-10 ). At 4 µg mL-1 , the parent compound PKZ18 significantly inhibited in vivo transcription of glycyl-tRNA synthetase mRNA. PKZ18 also inhibited in vivo translation of the S. aureus threonyl-tRNA synthetase protein. PKZ18 bound to the Specifier Loop in vitro (Kd ≈24 µm). Its core chemistry necessary for antibacterial activity has been identified. These findings support the T-box regulatory mechanism as a new target for antibiotic discovery that may impede the emergence of resistance.