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ACG Case Reports Journal Oct 2023Education in endoscopy encompasses a wide breadth of topics and skills. Despite a shared interest in improving training in endoscopy, there is wide variation among...
Education in endoscopy encompasses a wide breadth of topics and skills. Despite a shared interest in improving training in endoscopy, there is wide variation among programs, largely because of broad requirements put forth by the Accreditation Council on Graduate Medical Education. Historically, efforts to improve education in endoscopy were focused on numerics as a surrogate for competence. However, there is a role for "milestone" development goals to ensure trainees are on the right track to developing procedural competence. These milestones should encompass aspects of preprocedural assessment, intraprocedural technique, and postprocedural management and interpretation. Two important aspects of intraprocedural technique that are not universally emphasized among training programs but would be immensely beneficial to fellow education are (i) mucosal examination and (ii) device education. In this article, we will discuss the importance of developing the aforementioned skills and how we can approach a competency-based assessment of endoscopic skills during fellowship.
PubMed: 37799487
DOI: 10.14309/crj.0000000000001104 -
Journal of Education & Teaching in... Jul 2023This oral board case is appropriate for emergency medicine residents and medical students (with senior resident assistance) on emergency medicine rotation.
AUDIENCE
This oral board case is appropriate for emergency medicine residents and medical students (with senior resident assistance) on emergency medicine rotation.
INTRODUCTION
Although a somewhat rare disease, infant botulism is a true pediatric emergency that carried a 90% rate of mortality prior to the development of an antitoxin.1 While botulism infections can be iatrogenic, foodborne, or involve infected wounds, infant botulism remains the most common presentation of this disease and accounts for approximately 70% of new cases annually.2 Caused by , the inactive spores are ingested by the infant and germinate in the large intestine.3,4 The resulting neurotoxin prevents the release of acetylcholine at the presynaptic membrane which results in flaccid paralysis. Classically, the bulbar musculature is affected before somatic muscular, which results in the typical presentation of "descending paralysis."2,5 While confirmatory testing is important, it is often delayed by more than 24 hours, making both clinical recognition and implementation of treatment before confirmatory testing of vital importance.6,7 Treatment consists of providing airway, nutritional, and hydration support in addition to administering botulinum-specific antitoxin.8,9 While patients over the age of 12 months are treated with equine botulinum antitoxin, the Food and Drug Administration (FDA) has approved a human-derived immunoglobulin treatment, Botulism Immune Globulin Intravenous (BIG-IV, ie, "Baby BIG") for pediatric patients less than 12 months of age.1,2,6 Ordering BIG-IV is a complex and multidisciplinary process, requiring the treating physician to discuss any suspicious case with the Infant Botulism Treatment and Prevention Program (IBTPP) which is a branch of the California Department of Public Health.6 With early recognition and implementation of treatment, most infants will make a full recovery.
EDUCATIONAL OBJECTIVES
At the end of this oral board session, examinees will: 1) demonstrate an ability to obtain a complete pediatric medical history, 2) perform an appropriate physical exam on a pediatric patient, 3) investigate a broad differential diagnosis for neuromuscular weakness in a pediatric patient, 4) recognize the classic presentation of infant botulism and implement treatment with botulinum specific antitoxin before confirmatory testing, 5) recognize impending airway failure and intubate the pediatric patient with appropriately dosed medications and ET tube size, and 6) demonstrate effective communication with healthcare team members and parents.
EDUCATIONAL METHODS
This oral board case followed the standard American Board of Emergency Medicine-style case in a tertiary care hospital with access to all specialists and resources needed. This case was tested using 12 resident volunteers ranging from PGY 1-2 in an ACGME (Accreditation Council for Graduate Medical Education) accredited emergency medicine residency program. Learners were debriefed immediately after the case and were given the opportunity to provide feedback.
RESEARCH METHODS
The learners participating in the oral board case provided immediate feedback both by verbal discussion and via a written survey requiring them to rate the efficacy of the exercise. The efficacy of the educational content was assessed by comparing scoring measures of the ACGME core competencies across all learners based on post graduate year (PGY). Scoring measures were determined using a scale from 1-8, with 1-4 being unacceptable performance and 5-8 being acceptable. Efficacy required full completion of the oral board case by the residents as well as a debriefing session during which key educational concepts were discussed.
RESULTS
The practice oral board candidates consisted of 7 PGY1 and 5 PGY2 level residents. The average score of participating residents for each training level was PGY1: 4.5 and PGY2: 5.7. All except for 2 PGY2 residents missed at least one critical action with the majority of PGY1 residents missing more than one critical action for the case. All participating residents rated the educational value of the case as 4.75 (1-5 Likert scale, with 5 being excellent).
DISCUSSION
The educational content of this oral board case and debriefing session were effective for teaching the presentation, evaluation, and appropriate management of infant botulism. Infant botulism is a true pediatric emergency and prompt recognition and treatment is imperative in order to decrease mortality. While mortality was approximately 90% one hundred years ago, today infant botulism carries a much better prognosis due to the advent of antitoxin treatment with a mortality closer to 15%.1 This case highlights several classic physical exam findings including bulbar findings in addition to somatic weakness. Additionally, this case requires definitive airway management with endotracheal intubation, which is true for approximately 50% of infants with botulism.1 While a stool culture or direct toxin assay of the gastric contents, serum, or stool should be performed to confirm the diagnosis, these tests are often performed by the state health department or the Centers for Disease Control (CDC) and often take up to five days to result, during which time the patient will continue to deteriorate. Therefore, the treating physician should seek emergent consultation with the IBTPP to help facilitate the multidisciplinary decision to initiate treatment with human-derived anti-botulinum toxin antibodies.6 If the IBTPP deems that infant botulism is highly suspected based on the history and physical exam, then appropriate treatment should not be delayed and BIG-IV should be administered.6, 7 With early recognition and implementation of treatment, most infants will make a full recovery within several months to a year. Upon discharge, patients will likely require outpatient neurology follow-up in addition to physical therapy to aid in recovery. Because infant botulism is a true pediatric emergency with potentially high mortality, reaching the appropriate diagnosis expeditiously will allow the emergency physician to communicate effectively with worried parents regarding the disease progression and facilitate correct treatment early in order to prevent significant sequela.
TOPICS
Pediatric weakness, pediatric neurotoxin, infant botulism, neuromuscular weakness.
PubMed: 37575412
DOI: 10.21980/J88350 -
Clinics in Colon and Rectal Surgery Jul 2023Accreditation has played a major role in the evolution of health care quality as well as the structure and organization of American medicine. In its earliest iterations,... (Review)
Review
Accreditation has played a major role in the evolution of health care quality as well as the structure and organization of American medicine. In its earliest iterations, accreditation aimed to set a minimum standard of care, and now more prominently sets standards for high quality, optimal patient care. There are several institutions that provide accreditations that are relevant to colorectal surgery including the American College of Surgeons (ACS) Commission on Cancer, National Cancer Institute Cancer Center Designation, National Accreditation Program for Rectal Cancer, and the ACS Geriatrics Verification Program. While each program has unique criteria, the aim of accreditation is to assure high-quality evidenced-based care. In addition to these benchmarks, these programs provide avenues for collaboration and research between centers and programs.
PubMed: 37223226
DOI: 10.1055/s-0043-1761592 -
BJPsych International Nov 2023The first article written about psychiatric services in Qatar was published in in 2006. Since then, the health system in Qatar has undergone significant transformation... (Review)
Review
The first article written about psychiatric services in Qatar was published in in 2006. Since then, the health system in Qatar has undergone significant transformation in the areas of service delivery, research and education. International accreditations are sought in all these fields to emphasise the standard achieved. In this article, we follow up on the mental health services currently available in Qatar, their strengths and the associated challenges.
PubMed: 38029446
DOI: 10.1192/bji.2023.23 -
Acta Bio-medica : Atenei Parmensis Aug 2023endobronchial ultrasound has gained widespread popularity in the last decade, becoming the primary technique for minimally invasive evaluation of the mediastinum and... (Review)
Review
BACKGROUND AND AIM
endobronchial ultrasound has gained widespread popularity in the last decade, becoming the primary technique for minimally invasive evaluation of the mediastinum and staging of lung cancer. Several tertiary and quaternary care institutes use this method, performed by trained and accredited specialists. Its main indications are (I) diagnosis and staging of lung cancer, (II) mediastinal lymphadenopathy diagnosis (III) sampling peripheral pulmonary lesions.
CONCLUSIONS
this manuscript aims to describe the operational potential of both convex endobronchial ultrasound probe and radial endobronchial ultrasound probe technology, focusing on lung cancer. This narrative review is complemented with by the description of peculiar clinical cases in which endobronchial ultrasound played a pivotal role in reaching the diagnosis.
Topics: Humans; Lung Neoplasms; Mediastinum; Endosonography; Neoplasm Staging; Lymph Nodes
PubMed: 37539612
DOI: 10.23750/abm.v94i4.14090