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Megee PC, Uhley V, Grogan J, Silverman A. Foundational and Clinical Science Integration in a Team-Based Learning Module Modeling Care of a Patient With Dyslipidemia. MedEdPORTAL 2024; 20:11397. [PMID: 38595707 PMCID: PMC11001791 DOI: 10.15766/mep_2374-8265.11397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/14/2024] [Indexed: 04/11/2024]
Abstract
Introduction Foundational and clinical science integration, a long-standing goal of undergraduate medical education, benefits learners by promoting retention of critical knowledge and skills as well as their transfer to the clinical setting. We implemented a team-based learning (TBL) module in which foundational knowledge and skills from the disciplines of biochemistry, nutrition, and genetics were leveraged in a simulated patient encounter for diagnosis and management of a patient with dyslipidemia. Methods The TBL was deployed in a first-year medical student cardiovascular system course with 125 students over three academic years. Following individual and team readiness assurance tests (iRAT and tRAT, respectively), teams participated in an initial application exercise requiring consideration of clinical and laboratory data and other risk factors to engage the patient in a shared decision-making process. Using dietary and family history narratives in subsequent application exercises, teams completed recommendations for an individualized diet plan and an assessment of potential disease inheritance patterns to formulate appropriate patient care management strategies. Results Student engagement with prelearning materials and session team activities was high as judged by RAT performance and application exercise outcomes: iRAT question performance ranged from 89% to 99% for individual items, and tRAT performance was routinely 100%. Learners reported that the exercises were impactful and believed the learned foundational knowledge and skills were transferable to future patient care. Discussion The dyslipidemia TBL module provides an illustration for early clinical learners of how foundational knowledge and skills can be operationalized and transferred for optimal patient care.
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Affiliation(s)
- Paul C. Megee
- Associate Professor, Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine
| | - Virginia Uhley
- Associate Professor, Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine
| | - James Grogan
- Professor, Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine
| | - Alan Silverman
- Assistant Professor, Department of Internal Medicine, Oakland University William Beaumont School of Medicine; Clinical Assistant Professor, Department of Internal Medicine, Wayne State University School of Medicine
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Meisel JL, Chen DCR, Cohen GM, Bernard SA, Carmona H, Petrusa ER, Opole IO, Navedo D, Valtchinov VI, Nahas AH, Eiduson CM, Papps N. Listen Before You Auscultate: An Active-Learning Approach to Bedside Cardiac Assessment. MedEdPORTAL 2023; 19:11362. [PMID: 37915746 PMCID: PMC10615901 DOI: 10.15766/mep_2374-8265.11362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/28/2023] [Indexed: 11/03/2023]
Abstract
Introduction Bedside cardiac assessment (BCA) is deficient across a spectrum of noncardiology trainees. Learners not taught BCA well may become instructors who do not teach well, creating a self-perpetuating problem. To improve BCA teaching and learning, we developed a high-quality, patient-centered curriculum for medicine clerkship students that could be flexibly implemented and accessible to other health professions learners. Methods With a constructivist perspective, we aligned learning goals, activities, and assessments. The curriculum used a "listen before you auscultate" framework, capturing patient history as context for a six-step, systematic approach. In the flipped classroom, short videos and practice questions preceded two 1-hour class activities that integrated diagnostic reasoning, pathophysiology, physical diagnosis, and reflection. Activities included case discussions, jugular venous pressure evaluation, heart sound competitions, and simulated conversations with patients. Two hundred sixty-eight students at four US and international medical schools participated. We incorporated feedback, performed thematic analysis, and assessed learners' confidence and knowledge. Results Low posttest data capture limited quantitative results. Students reported increased confidence in BCA ability. Knowledge increased in both BCA and control groups. Thematic analysis suggested instructional design strategies were effective and peer encounters, skills practice, and encounters with educators were meaningful. Discussion The curriculum supported active learning of day-to-day clinical competencies and promoted professional identity formation alongside BCA ability. Feedback and increased confidence on the late-clerkship posttest suggested durable learning. We recommend approaches to confirm this and other elements of knowledge, skill acquisition, or behaviors and are surveying impacts on professional identity formation-related constructs.
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Affiliation(s)
- James L. Meisel
- Associate Chief of Staff for Education, VA Bedford Healthcare System; Associate Professor of Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine
| | - Daniel C. R. Chen
- Assistant Dean of Student Affairs and Clinical Associate Professor of Medicine, General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine
| | | | - Sheilah A. Bernard
- Associate Professor of Medicine, Cardiovascular Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine
| | - Hugo Carmona
- Assistant Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine
| | - Emil R. Petrusa
- Professor of Surgery, Harvard Medical School, and Department of Surgery, Learning Lab, Massachusetts General Hospital
| | - Isaac O. Opole
- Professor of Internal Medicine, Department of Internal Medicine, University of Kansas Medical Center
| | - Deborah Navedo
- Director of Education, STRATUS Center for Simulation, Brigham and Women's Hospital
| | - Vladimir I. Valtchinov
- Assistant Professor of Radiology, Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, and Department of Biomedical Informatics, Harvard Medical School
| | - Ahmed H. Nahas
- Advanced Geriatric Medicine Fellow, New England Geriatric Research Education and Clinical Center, VA Boston Health Care System, and Harvard Medical School Multicampus Geriatrics Fellowship, Beth Israel Deaconess Medical Center; Family Physician and Geriatrician, Family Medicine Clinic, Yakima Valley Farm Workers Clinic
| | - Carly M. Eiduson
- Fourth-Year Medical Student, University of Rochester School of Medicine & Dentistry
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Sumski CA, Singh A, Rogers A, Treat R, Bergstrom C. Cardiac Physical Exam Skills and Auscultation Session for Pediatric Interns. MedEdPORTAL 2022; 18:11289. [PMID: 36605544 DOI: 10.15766/mep_2374-8265.11289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 09/23/2022] [Indexed: 12/24/2022]
Abstract
Introduction Physicians need adequate physical exam skills. Unfortunately, interns have variable physical exam skills, and teaching is often limited to rounds, an inconsistent setting. Physical exam skills, particularly those involving auscultation, require practice. Our goal was to create a cardiac physical exam workshop for pediatric interns that would improve their performance on an interactive assessment of their ability and understanding in physical exam and murmur interpretation. Methods We completed a targeted needs assessment and then developed a 2-hour workshop on the pediatric cardiac physical exam targeted to pediatrics residents. The workshop included didactics, group discussion, and practice interpreting common pediatric murmurs. Pediatrics residents completed the assessment as a pretest and then participated in the workshop. At the end of the workshop, the assessment was administered as a posttest, followed by a reassessment 3 months later. Nonparametric statistical analysis was conducted. Pre- and posttest scores were compared using the Wilcoxon signed rank test. Results Twenty-five residents completed the workshop, including 22 pediatrics residents, one pediatrics/anesthesia combined resident, one pediatric neurology resident, and one resident completing a preliminary year in pediatrics prior to dermatology residency. There was a significant increase in the mean score on the assessment from pre- to posttest (pretest M = 54%, posttest M = 71%, p < .001). This increase was sustained at the 3-month reassessment (M = 67%). Discussion This cardiac physical exam workshop demonstrated improvement in physical exam knowledge and interpretation ability as measured by an online pre-/posttest.
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Abstract
Coexisting dysfunction of heart and kidney, the cardiorenal syndrome, is a common condition and is associated with worsening of outcomes and complexities of diagnostic, preventive, and therapeutic approaches. The knowledge of the physiology of heart and kidney and their interaction with each other and with other organ systems has progressed significantly in recent years, resulting in a better understanding of the pathogenesis of cardiorenal syndrome. A robust knowledge of the pathophysiology and of the latest practical advancements about cardiorenal syndrome is necessary for cardiologists, nephrologists, and other practitioners who provide medical care to the patients with heart and kidney diseases.
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Affiliation(s)
- Parta Hatamizadeh
- Department of Medicine, Division of Nephrology, Hypertension & Renal Transplantation, University of Florida, 1600 SW Archer Road, CG-98, PO Box 100224, Gainesville, FL 32610, USA.
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Jain S, Feldman R, Althouse AD, Spagnoletti C, Proksell S. A Nutrition Counseling Curriculum to Address Cardiovascular Risk Reduction for Internal Medicine Residents. MedEdPORTAL 2020; 16:11027. [PMID: 33204843 PMCID: PMC7666832 DOI: 10.15766/mep_2374-8265.11027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 07/07/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Primary care providers play a critical role in reducing patients' risk for cardiovascular disease, including providing dietary counseling. However, few physicians feel adequately trained to provide this counseling, and most internal medicine (IM) residencies do not offer nutrition education. METHODS We created an interactive, case-based activity for IM residents to improve the delivery of nutrition counseling to patients with hypertension, hyperlipidemia, overweight, and obesity. The curriculum was given over two in-person small-group sessions facilitated by physician preceptors. It reviewed evidence for relevant dietary patterns, provided resources for dietary referrals, and allowed residents to practice counseling based on a patient's stage of behavioral change. RESULTS Residents completed electronic surveys prior to curriculum implementation, immediately after, and 2 months after completion of the curriculum. Aggregate percent correct scores of knowledge questions improved significantly in the immediate postsurvey (n = 24 paired responses, p = .004). We also reviewed electronic health records of patients with body mass index ≥ 25, hypertension, or hyperlipidemia who were seen in our resident clinics 2 months prior (n = 503) and 2 months after (n = 473) curriculum delivery. Residents' documented nutrition counseling increased from 35% to 41% (odds ratio, 1.27; 95% CI, 0.97-1.67; p = .085). DISCUSSION We demonstrated improved knowledge of nutrition interventions to reduce cardiovascular risk and reported improvement of resident-provided nutrition counseling for appropriate patients. This activity offers IM residents effective initial nutrition training for patients at risk for cardiovascular disease and is practical to implement as part of an ambulatory curriculum.
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Affiliation(s)
- Seema Jain
- Assistant Instructor, Division of General Internal Medicine, University of Texas Southwestern Medical Center
| | - Robert Feldman
- Data Analyst, Center for Research on Health Care (CRHC) Data Center, University of Pittsburgh
| | - Andrew D. Althouse
- Assistant Professor, Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Carla Spagnoletti
- Professor, Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Siobhan Proksell
- Assistant Professor, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine
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Jackson JM, Stacey RB, Korczyk SS, Williams DM. The Simulated Cardiology Clinic: A Standardized Patient Exercise Supporting Medical Students' Biomedical Knowledge and Clinical Skills Integration. MedEdPORTAL 2020; 16:11008. [PMID: 33150203 PMCID: PMC7597946 DOI: 10.15766/mep_2374-8265.11008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/16/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Development of cardiac disease-related diagnostic skills-including hypothesis-driven data gathering, heart sound interpretation, and ECG interpretation-is an important component of medical student training. Prior studies indicate trainees' performance of these skills is limited. Simulation provides students with opportunities to practice integrating their developing knowledge in a relevant clinical context. We developed a simulated clinic activity for second-year medical students consisting of standardized patient (SP) cases representing cardiovascular (CV) diseases. METHODS Student small groups rotated through four SP encounters. For each case, one student performed the history, after which the whole small group listened to audio files of heart sounds, interpreted an ECG, and collaboratively developed a prioritized differential diagnosis. The CV course director met with students for a large-group debrief, highlighting key learning points. We collected learners' evaluations of the event through an online survey. RESULTS Of students, 276 participated in this activity over the course of 2 years. Nearly all students assessed the activity as extremely or quite effective for applying learning content from the CV course (97%, 2018; 93%, 2019), and for practicing how to approach chest pain, shortness of breath, palpitations, and fatigue (100%, 2018; 95%, 2019). The most helpful aspects were reinforcement of CV disease illness scripts, hypothesis-driven data gathering practice, ECG interpretation, and applying knowledge and skills in a realistic context. DISCUSSION SP encounters representing CV conditions can effectively provide opportunities for students to integrate basic science knowledge and clinical skills. Students assessed the activity as helpful and engaging.
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Affiliation(s)
- Jennifer M. Jackson
- Associate Professor, Department of Pediatrics, Wake Forest School of Medicine
| | - R. Brandon Stacey
- Associate Professor, Cardiology, Department of Internal Medicine, Wake Forest School of Medicine
| | | | - Donna M. Williams
- Associate Professor, Department of Internal Medicine, Wake Forest School of Medicine
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Kurtz J, Holman B, Monrad SU. Training Medical Students to Create and Collaboratively Review Multiple-Choice Questions: A Comprehensive Workshop. MedEdPORTAL 2020; 16:10986. [PMID: 33083537 PMCID: PMC7549389 DOI: 10.15766/mep_2374-8265.10986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 04/13/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Multiple-choice question (MCQ) creation is an infrequently used active-learning strategy. Previous studies demonstrated that medical students find value in the process, but have minimal training, which may limit potential learning benefits. We therefore developed a process for question-creation that required students to complete in-depth training, in addition to collaborative question-writing and editing. METHODS We created a question-writing workshop consisting of three components: (1) training in MCQ writing utilizing NBME online modules, a practice MCQ-writing session, and a training session, (2) writing MCQs independently after choosing topics from an institutionally generated blueprint, and (3) reviewing and editing MCQs via an in-person session. To understand students' perceptions, we held two four-student focus groups and recorded/transcribed the data. We iteratively reviewed the transcripts to generate a codebook and corresponding themes. We used the focus group data to generate a survey with Likert-scale questions, which we sent to the remaining 10 students and analyzed using Microsoft Excel. RESULTS Eighteen second-year medical students participated in this workshop. Students perceived that question-writing training (3.7/5.0±0.5) and question writing (3.9/5.0±0.3) benefitted their learning. Students perceived that MCQ writing required concept integration (4.1/5.0±0.6). Students described how question writing allowed them to recognize subtle distinctions between therapies and diagnoses. Each MCQ required about 1.5 hours to write and collaboratively edit. DISCUSSION Our results demonstrated that students perceived question writing to benefit their learning. More importantly, students felt that question writing actively engaged them to integrate content and compare concepts; students' engagement suggests that they learned from this question-writing activity.
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Affiliation(s)
- Josh Kurtz
- Fourth-year medical student, University of Michigan Medical School
| | - Beth Holman
- Associate Director of Assessment and Evaluation, University of Michigan Medical School
| | - Seetha U. Monrad
- Assistant Dean for Assessment, Evaluation, and Quality Improvement; Associate Professor of Internal Medicine and Learning Health Sciences, University of Michigan Medical School
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Jackson JM, Strowd LC, Peters TR. The Simulated Virology Clinic: A Standardized Patient Exercise for Preclinical Medical Students Supporting Basic and Clinical Science Integration. MedEdPORTAL 2020; 16:10957. [PMID: 32934980 PMCID: PMC7485908 DOI: 10.15766/mep_2374-8265.10957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/19/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Virology is inherently challenging due to the sheer volume of information medical students are responsible for learning. Cognitive integration of this content is critical for early medical students to practice applying this knowledge to diagnostic problem-solving. Simulation offers learners engaging opportunities to practice cognitive integration. We developed a simulated clinic activity for first-year medical students consisting of standardized patient (SP) encounters representing viral infections. METHODS Student small groups rotated through eight SP encounters during which they collected patient histories, reviewed physical exam findings, and developed a differential diagnosis and diagnostic plan for each case. The instructor debriefed students on the cases afterward. We assessed students' evaluation of the activity through online surveys. RESULTS Two hundred seventy-eight students participated in the simulated clinic in 2018 and 2019. Students rated the activity as very effective for learning about the infections represented and for providing opportunities to integrate clinical skills. Students agreed that the event's instructional design was appropriate for its objectives and that the problem-solving aspect was intellectually stimulating. They indicated that the most effective aspects were solidifying illness scripts for the infections represented, integrating knowledge and skills to diagnose patients in a realistic clinical context, and working collaboratively to problem-solve. DISCUSSION The simulated virology clinic is an effective method for providing students opportunities to integrate microbiology and clinical skills and has been positively received by students. This instructional method offers learners an opportunity to solidify illness scripts for viral infections using an interactive, collaborative approach.
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Affiliation(s)
- Jennifer M. Jackson
- Associate Professor, Department of Pediatrics, Wake Forest School of Medicine; Co-Course Director, Clinical Skills Curriculum, Wake Forest School of Medicine; Co-Course Director, Virology Course, Wake Forest School of Medicine; Assistant Dean for Curricular Innovation, Wake Forest School of Medicine
| | - Lindsay C. Strowd
- Assistant Professor, Department of Dermatology, Wake Forest School of Medicine; Director, Dermatology Thread, Wake Forest School of Medicine
| | - Timothy R. Peters
- Professor, Department of Pediatrics, Wake Forest School of Medicine; Associate Dean for Educational Strategy & Innovation, Wake Forest School of Medicine; Co-Course Director, Virology Course, Wake Forest School of Medicine
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Klein AJ, Berlacher M, Doran JA, Corbelli J, Rothenberger SD, Berlacher K. A Resident-Authored, Case-Based Electrocardiogram Email Curriculum for Internal Medicine Residents. MedEdPORTAL 2020; 16:10927. [PMID: 32821805 PMCID: PMC7431182 DOI: 10.15766/mep_2374-8265.10927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 01/10/2020] [Indexed: 11/18/2022]
Abstract
Introduction The interpretation of electrocardiograms (ECGs) is a critical competency for internal medicine trainees, yet time and resources to foster proficiency are limited. Methods This resident-authored ECG email curriculum for first-year residents involved 129 first-year internal medicine residents at three major academic university hospitals. Residents either received the resident-authored ECG email curriculum (intervention group) or continued standard training (control group). The curriculum involved 10 multiple-choice ECG cases emailed biweekly over the 6-month study period. All participants were asked to complete a pre- and postintervention test to assess ECG interpretation competency and attitudes. The primary outcome was improvement in ECG test performance. Results Among the 129 first-year residents participating, 21 of the 65 (32%) randomized to the intervention group and 13 of the 64 (20%) randomized to the control group completed both the pre- and posttests for analysis. While all participants' ECG test scores improved over the study period (p < .001), improvement did not differ between groups (p = .860). We found that the effect of the intervention on ECG test performance varied significantly by the number of cardiology rotations an intern experienced (p = .031), benefiting naïve learners the most. All intervention group participants who completed the posttest reported they would recommend it to a colleague. Discussion While it did not improve resident performance on an ECG posttest, this resident-authored ECG email curriculum offers a scalable way to provide trainees additional practice with ECG interpretation, with particular benefit to trainees who have not yet rotated on cardiology.
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Affiliation(s)
- Andrew J. Klein
- Clinical Instructor, Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Mark Berlacher
- Fellow, Department of Cardiology, University of Texas Southwestern Medical Center
| | - Jesse A. Doran
- Fellow, Division of Cardiology, University of Rochester Medical Center
| | - Jennifer Corbelli
- Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Scott D. Rothenberger
- Assistant Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Kathryn Berlacher
- Assistant Professor of Medicine, Heart and Vascular Institute, University of Pittsburgh School of Medicine
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Mirijello A, Curci S, D'Errico MM, De Cosmo S. 'Bony' heart. BMJ Case Rep 2019; 12:12/8/e231793. [PMID: 31473644 DOI: 10.1136/bcr-2019-231793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Antonio Mirijello
- Department of Medical Sciences, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Serafino Curci
- Department of Medical Sciences, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Maria Maddalena D'Errico
- Department of Medical Sciences, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Salvatore De Cosmo
- Department of Medical Sciences, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
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Barry DS, Dent JM, Hankin M, Moyer D, Shah NL, Tuskey A, Soukoulis V. The Clinical Anatomy and Imaging Laboratory: Vertical Integration in the Preclerkship Curriculum. MedEdPORTAL 2019; 15:10824. [PMID: 31161136 PMCID: PMC6543925 DOI: 10.15766/mep_2374-8265.10824] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 03/29/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION As medical schools implement integrated curricula, anatomy education especially has experienced increased pressure to make foundational content clinically relevant. We designed a novel type of integrative anatomy laboratory experience where students could use foundational anatomy concepts in concert with modern imaging/diagnostic techniques to enhance important clinical concepts. METHODS We selected a process called Lesson Study to develop the multidisciplinary Clinical Anatomy and Imaging Laboratory (CAIL) in the cardiovascular and gastrointestinal systems. We utilized soft-embalmed cadavers extensively for their highly realistic tissue appearance and texture, which allowed instructors and students to perform a wide array of procedures in case-based scenarios similar to practicing clinicians. We conducted field observations of participating students, focus-group discussions, and knowledge-based exams to examine efficacy of the CAIL. RESULTS Approximately 150 first- and second-year students participated in each of the CAIL activities on an annual basis. Most focus-group participants felt the CAIL was a great learning experience. They commented on how the lab provided relevance to anatomy knowledge and helped integrate prior classroom learning more deeply. Instructors noted that students asked more advanced, clinically relevant questions than in a typical anatomy lab. Knowledge improved significantly after the CAIL, although it is unclear if this translates to summative exams. DISCUSSION The CAIL creates a unique learning experience where students use prior foundational anatomy knowledge in conjunction with modern imaging and diagnostic techniques to reinforce important clinical concepts. We have continued to integrate CAIL experiences into more clinical systems in our medical school curriculum.
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Affiliation(s)
- Deborah S. Barry
- Assistant Professor, Medical Education, University of Virginia School of Medicine
| | - John M. Dent
- Professor, Medicine: Division of Cardiovascular Medicine, University of Virginia School of Medicine
| | - Mark Hankin
- Professor, Medical Education, University of Virginia School of Medicine
| | - David Moyer
- Assistant Professor, Medical Education, University of Virginia School of Medicine
- Director of Anatomy, Medical Education, University of Virginia School of Medicine
| | - Neeral L. Shah
- Associate Professor, Medicine: Division of Gastroenterology and Hepatology, University of Virginia School of Medicine
| | - Anne Tuskey
- Associate Professor, Medicine: Division of Gastroenterology and Hepatology, University of Virginia School of Medicine
| | - Victor Soukoulis
- Professor, Medicine: Division of Cardiovascular Medicine, University of Virginia School of Medicine
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Ojha V, Pandey NN, Jagia P. Hemiazygos continuation of isolated left-sided inferior vena cava into persistent left superior vena cava: rare association of left isomerism. BMJ Case Rep 2019; 12:12/4/e230350. [PMID: 31005880 DOI: 10.1136/bcr-2019-230350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Vineeta Ojha
- Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Niraj Nirmal Pandey
- Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Priya Jagia
- Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Aktaa S, Fatania K, Gains C, White H. Chest pain following permanent pacemaker insertion… a case of pneumopericardium due to atrial lead perforation. BMJ Case Rep 2018; 2018:bcr-2018-226318. [PMID: 30366893 PMCID: PMC6203003 DOI: 10.1136/bcr-2018-226318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Permanent pacemaker (PPM) implantation is an increasingly common procedure with complication rate estimated between 3% and 6%. Cardiac perforation by pacemaker lead(s) is rare, but a previous study has shown that it is probably an underdiagnosed complication. We are presenting a case of a patient who presented 5 days after PPM insertion with new-onset pleuritic chest pain. She had a normal chest X-ray (CXR), and acceptable pacing checks. However, a CT scan of the chest showed pneumopericardium and pneumothorax secondary to atrial lead perforation. The pain only settled by replacing the atrial lead. A repeat chest CT scan a few months later showed complete resolution of the pneumopericardium and pneumothorax. We believe that cardiac perforation can be easily missed if associated with normal CXR and acceptable pacing parameters. Unexplained chest pain following PPM insertion might be the only clue for such complication, although it might not always be present.
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Affiliation(s)
- Suleman Aktaa
- Department of Cardiology, Mid Yorkshire Hospitals NHS Trust, Wakefield, West Yorkshire, UK
| | - Kavi Fatania
- Department of Radiology, Mid Yorkshire Hospitals NHS Trust, Wakefield, West Yorkshire, UK
| | - Claire Gains
- Department of Radiology, Mid Yorkshire Hospitals NHS Trust, Wakefield, West Yorkshire, UK
| | - Hazel White
- Department of Cardiology, Mid Yorkshire Hospitals NHS Trust, Wakefield, West Yorkshire, UK
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Affiliation(s)
- Dominika M Zoltowska
- Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan, USA
| | - Jagadeesh K Kalavakunta
- Cardiology, Borgess Medical Center/Michigan State University/Western Michigan University School of Medicine, Kalamazoo, Michigan, USA
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Faltado AL, Sandoval MAS, Kaw L. Peripheral arterial disease as seen on X-ray and arteriography. BMJ Case Rep 2017; 2017:bcr-2017-221873. [PMID: 29141927 DOI: 10.1136/bcr-2017-221873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Antonio Lumbera Faltado
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Mark Anthony Santiago Sandoval
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Leoncio Kaw
- Section of Thoracic and Cardiovascular Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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Thangaswamy CR, Manikandan R, Bathala Vedagiri SC. Role of transoesophageal echocardiography in renal cell carcinoma: a brief review. BMJ Case Rep 2017; 2017:bcr-2017-221532. [PMID: 29030366 DOI: 10.1136/bcr-2017-221532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Transoesophageal echocardiography (TOE) is regularly used in cardiac and also increasingly in non-cardiac surgeries. It has a leading role in the perioperative management of renal cell carcinoma with tumour extension into inferior vena cava. We report two cases in which TOE was of immense help for patient management. This report highlights the two cases where intraoperative TOE was of immense help to establish diagnosis, to modify surgical plan, to guide the surgeon during clamp placement, to monitor cardiac function, to rule out tumour embolism and to confirm the complete removal of tumour thrombus.
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Affiliation(s)
- Chitra Rajeswari Thangaswamy
- Department of Anaesthesiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, Tamilnadu, India
| | - Ramanitharan Manikandan
- Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, Tamilnadu, India
| | - Sai Chandran Bathala Vedagiri
- Department of Cardiothoracic and Vascular Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, Tamilnadu, India
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17
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Orellana-Barrios M, Sotello Aviles DA, Oyenuga O, Nugent K. Implantable cardiac defibrillator infections: the emerging importance of Mycobacterium fortuitum. BMJ Case Rep 2017; 2017:bcr-2017-221934. [PMID: 28928258 DOI: 10.1136/bcr-2017-221934] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Infection is a clinically relevant complication associated with intracardiac devices. Atypical mycobacteria, particularly Mycobacterium fortuitum, have been increasingly implicated in cardiovascular implantable electronic device (CIED) infections. We present a case of M. fortuitum CIED infection in a patient with ischaemic cardiomyopathy occurring approximately 3 weeks after insertion. The recognition and adequate treatment, including device removal, tissue sampling and the determination of antimicrobial sensitivities, are essential in the proper management of these patients.
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Affiliation(s)
| | | | | | - Kenneth Nugent
- Department t of Internal Medicine Critical Care, TTUHSC, Lubbock, Texas, USA
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18
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Affiliation(s)
- Mayur Patel
- Internal Medicine, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Zeshan Ahmad
- Internal Medicine, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Edward Distler
- Internal Medicine, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Brenen Swofford
- Internal Medicine, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
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Abstract
Cor triatriatum sinistrum (CTS) is a congenital anomaly where the left atrium is divided into two compartments by a fibromuscular membrane. This report aims to add to the literature on a rare cardiac condition that can cause neurological morbidity. We report a case of a 19-year-old female with an infarct in the right middle cerebral artery (MCA) territory initially maintained on aspirin. Eighteen months later, she had recurrence of weakness, for which repeat transthoracic echocardiography (TTE) and re-evaluation of the first TTE demonstrated a hyperechoic membrane spanning the width of the left atrium, clinching the diagnosis of CTS. Despite anticoagulation with apixaban, she was admitted for a third stroke where she succumbed to hospital-acquired pneumonia. Among cases of CTS associated with stroke, anticoagulation and surgery were the main modes of treatment. This case has the longest follow-up and the first to demonstrate failure of antiplatelet therapy and anticoagulation.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- Department of Neurosciences, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | | | - Eddieson Masangcay Gonzales
- Department of Medicine, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | | | - Adrian Isidro Espiritu
- Department of Neurosciences, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Jose Leonard Rivera Pascual
- Department of Neurosciences, Philippine General Hospital, University of the Philippines, Manila, Philippines.,Department of Anatomy, College of Medicine, University of the Philippines- Manila, Manila, Philippines
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20
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Ahmed M, Aziz H, Jiang L. Severe aortic complications in a patient with variant Shone's complex and bicuspid aortic valve. BMJ Case Rep 2017; 2017:bcr-2017-221348. [PMID: 28790051 DOI: 10.1136/bcr-2017-221348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Mashrafi Ahmed
- Department of Cardiovascular Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Hany Aziz
- Department of Cardiovascular Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Leng Jiang
- Department of Cardiovascular Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
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21
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Booth AL, Li CQ, Al-Dossari GA, Stevenson HL. Abundant dystrophic calcifications mimicking aortic valve abscess in a patient undergoing elective aortic valve replacement. BMJ Case Rep 2017; 2017:bcr-2017-220368. [PMID: 28729377 PMCID: PMC5535045 DOI: 10.1136/bcr-2017-220368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Dystrophic calcifications of the aortic valve may cause symptomatic aortic stenosis and account for a significant portion of patients who undergo elective valve replacement. Calcifications appearing grossly as a cloudy fluid surrounding the aortic valve leaflets are an uncommon finding. Normally, calcified aortic valves are characterised by large, nodular masses within the aortic cusps. We report a case of dystrophic calcifications on a stenotic aortic valve encountered intraoperatively, which was suggestive of infective endocarditis and abscess formation. Aortic valve leaflets and necrotic-appearing thymic lymph node tissue were submitted for histology and special stains. Cultures were negative and histology did not show evidence of infection. Tissue histology demonstrated extensive dystrophic calcifications, which were polarised to reveal abundant calcium oxalate crystals. The benign nature of this unique pathological finding ruled out any suspicion of infection, avoiding a prolonged course of intravenous antibiotics in this patient.
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Affiliation(s)
- Adam L Booth
- Department of Pathology, University of Texas Medical Branch , Galveston, Texas, USA
| | - Christine Q Li
- Department of Pathology, University of Texas Medical Branch , Galveston, Texas, USA
| | | | - Heather L Stevenson
- Department of Pathology, University of Texas Medical Branch , Galveston, Texas, USA
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22
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Walsh JL, Harris BHL, Gharzuddine W, Isma'eel H. Myocardial infarction masquerading as myocarditis in a patient with factor V Leiden: unmasked with MR. BMJ Case Rep 2017; 2017:bcr-2017-220652. [PMID: 28720694 DOI: 10.1136/bcr-2017-220652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a case of a 21-year-old man presenting with sharp left-sided chest pain. A CT pulmonary angiogram was negative, ECG was unremarkable and a mild troponin rise was observed. Myocarditis was suspected as the most likely diagnosis, particularly in view of the patient's previous diagnosis of myocarditis 3 years prior. A cardiac MRI was indicative of an acute mid-anterior myocardial infarction (MI) and an old inferior MI with an associated aneurysm. A subsequent angiogram revealed a subtotal occlusion in the second diagonal artery, likely precipitated by homozygous factor V Leiden.This case illustrates the value of MRI in differentiating acute MI from myocarditis when clinical suspicion is low, as in this young patient with atypical chest pain. Further, it demonstrates the value of MRI in detecting previous MIs and reinforces the importance of searching for precipitants of MI in young patients.
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Affiliation(s)
- Jason Leo Walsh
- American University of Beirut Medical Center, Beirut, Lebanon
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Abstract
A 6-month-old female infant was referred with a 3-day history of low-grade fever, slight nasal congestion and rhinorrhoea. On admission, the clinical findings were unremarkable and she was discharged home. However, she became progressively more listless with a decreased urine output and was once again seen in the emergency department. Analytically she was found to have metabolic acidosis, hyperkalaemia, thrombocytopaenia, anaemia and schistocytes in the peripheral blood smear. Based on these findings, the diagnosis of haemolyticâ-uremic syndrome was made. A few hours postadmission, there was an abrupt clinical deterioration. She went into cardiorespiratory arrest and she was successfully resuscitated. An ST-segment elevation was noted on the ECG monitor and the troponin I levels were raised, suggesting myocardial infarction. Despite intensive supportive therapy, she went into refractory shock and died within 30 hours.
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Affiliation(s)
- Natália Noronha
- Serviáo de Cuidados Intensivos Pediátricos, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Filipa Dias Costa
- Serviáo de Cuidados Intensivos Pediátricos, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Andrea Dias
- Serviáo de Cuidados Intensivos Pediátricos, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Alexandra Dinis
- Serviáo de Cuidados Intensivos Pediátricos, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Portugal
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24
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Abstract
A 19-year-old male patient was referred by his general practitioner with a new 'cardiac murmur'. For 1 week, he had been able to provoke a clicking sound, which was in time with his heart beat and originated from his chest. The physical examination and laboratory tests were normal. The sound was initially interpreted as most likely due to a valve condition such as mitral valve prolapse, but a transthoracic echocardiogram was normal. A cardiac CT was obtained, which showed left-sided ventral pneumothorax.The Hamman's sign is a loud precordial pulse synchronous sound, which is often postural. It is pathognomonic for left-sided pneumothorax or pneumomediastinum. Hamman's sign as a presenting symptom is rare, but if present is key to diagnosis. The awareness of rare clinical findings is important and will prevent unnecessary diagnostic tests.
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Affiliation(s)
| | - Christopher Hansi
- Division of Cardiology, Department of Medicine, Kantonsspital Baden, Baden, Switzerland
| | - Urs Hufschmid
- Division of Cardiology, Department of Medicine, Kantonsspital Baden, Baden, Switzerland
| | - Juerg Hans Beer
- Department of Internal Medicine, Kantonsspital Baden, Baden, Switzerland
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25
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Dattani A, Jackson A. The cause of the stroke: a diagnostic uncertainty. BMJ Case Rep 2017. [PMID: 28645902 DOI: 10.1136/bcr-2016-218358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 39-year-old man with a history of sickle cell disease (SCD) presented with left leg weakness. He had a normal CT head and CT angiogram, but MRI head showed multiple acute bilateral cortical infarcts including in the right precentral gyrus. The MRI findings were more in keeping with an embolic source rather than stroke related to SCD, although it could not be ruled out. He also had an echocardiogram which revealed a patent foramen ovale. He was treated with antiplatelet therapy and also had red blood cell exchange transfusion. His symptoms improved significantly and he was discharged with follow-up as an outpatient and a cardiology review.
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Affiliation(s)
| | - Ava Jackson
- Stroke and Geriatric Medicine, Barts Health NHS Trust, London, UK
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26
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Ortiz A, Abiose A, Bichet DG, Cabrera G, Charrow J, Germain DP, Hopkin RJ, Jovanovic A, Linhart A, Maruti SS, Mauer M, Oliveira JP, Patel MR, Politei J, Waldek S, Wanner C, Yoo HW, Warnock DG. Time to treatment benefit for adult patients with Fabry disease receiving agalsidase β: data from the Fabry Registry. J Med Genet 2016; 53:495-502. [PMID: 26993266 PMCID: PMC4941144 DOI: 10.1136/jmedgenet-2015-103486] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 02/23/2016] [Indexed: 11/29/2022]
Abstract
Background Agalsidase β is a form of enzyme replacement therapy for Fabry disease, a genetic disorder characterised by low α-galactosidase A activity, accumulation of glycosphingolipids and life-threatening cardiovascular, renal and cerebrovascular events. In clinical trials, agalsidase β cleared glycolipid deposits from endothelial cells within 6 months; clearance from other cell types required sustained treatment. We hypothesised that there might be a ‘lag time’ to clinical benefit after initiating agalsidase β treatment, and analysed the incidence of severe clinical events over time in patients receiving agalsidase β. Methods The incidence of severe clinical events (renal failure, cardiac events, stroke, death) was studied in 1044 adult patients (641 men, 403 women) enrolled in the Fabry Registry who received agalsidase β (average dose 1 mg/kg every 2 weeks) for up to 5 years. Results The incidence of all severe clinical events was 111 per 1000 person-years (95% CI 84 to 145) during the first 6 months. After 6 months, the incidence decreased and remained stable within the range of 40–58 events per 1000 patient-years. The largest decrease in incidence rates was among male patients and those aged ≥40 years when agalsidase β was initiated. Conclusions Contrary to the expected increased incidence of severe clinical events with time, adult patients with Fabry disease had decreased incidence of severe clinical events after 6 months treatment with agalsidase β 1 mg/kg every 2 weeks. Trial registration number NCT00196742.
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Affiliation(s)
- Alberto Ortiz
- Unidad de Dialisis, IIS-Fundacion Jimenez Diaz/UAM, IRSIN, Madrid, Spain
| | | | - Daniel G Bichet
- Hôpital du Sacré-Coeur de Montréal and University of Montreal, Montreal, QC, Canada
| | | | - Joel Charrow
- Division of Genetics, Birth Defects, and Metabolism, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dominique P Germain
- Division of Medical Genetics, University of Versailles-St Quentin en Yvelines, Versailles, France Assistance Publique-Hôpitaux de Paris, Garches, France
| | - Robert J Hopkin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ana Jovanovic
- Department of Endocrinology and Metabolic Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Aleš Linhart
- Department of Internal Medicine, School of Medicine, Charles University, Prague, Czech Republic
| | - Sonia S Maruti
- Genzyme, a Sanofi Company, Cambridge, Massachusetts, USA
| | - Michael Mauer
- Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - João P Oliveira
- Department of Genetics, São João Hospital Centre & Faculty of Medicine, University of Porto, Porto, Portugal I3S-Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
| | - Manesh R Patel
- Division of Cardiovascular Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Juan Politei
- Department of Neurology, Fundacion Para el Estudio de Enfermedades Neurometabolicas (FESEN), Buenos Aires, Argentina
| | | | - Christoph Wanner
- Division of Nephrology, University Clinic, University of Würzburg, Würzburg, Germany
| | - Han-Wook Yoo
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - David G Warnock
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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27
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Futema M, Plagnol V, Li K, Whittall RA, Neil HAW, Seed M, Bertolini S, Calandra S, Descamps OS, Graham CA, Hegele RA, Karpe F, Durst R, Leitersdorf E, Lench N, Nair DR, Soran H, Van Bockxmeer FM, Humphries SE. Whole exome sequencing of familial hypercholesterolaemia patients negative for LDLR/APOB/PCSK9 mutations. J Med Genet 2014; 51:537-44. [PMID: 24987033 PMCID: PMC4112429 DOI: 10.1136/jmedgenet-2014-102405] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Familial hypercholesterolaemia (FH) is an autosomal dominant disease of lipid metabolism, which leads to early coronary heart disease. Mutations in LDLR, APOB and PCSK9 can be detected in 80% of definite FH (DFH) patients. This study aimed to identify novel FH-causing genetic variants in patients with no detectable mutation. Methods and results Exomes of 125 unrelated DFH patients were sequenced, as part of the UK10K project. First, analysis of known FH genes identified 23 LDLR and two APOB mutations, and patients with explained causes of FH were excluded from further analysis. Second, common and rare variants in genes associated with low-density lipoprotein cholesterol (LDL-C) levels in genome-wide association study (GWAS) meta-analysis were examined. There was no clear rare variant association in LDL-C GWAS hits; however, there were 29 patients with a high LDL-C SNP score suggestive of polygenic hypercholesterolaemia. Finally, a gene-based burden test for an excess of rare (frequency <0.005) or novel variants in cases versus 1926 controls was performed, with variants with an unlikely functional effect (intronic, synonymous) filtered out. Conclusions No major novel locus for FH was detected, with no gene having a functional variant in more than three patients; however, an excess of novel variants was found in 18 genes, of which the strongest candidates included CH25H and INSIG2 (p<4.3×10−4 and p<3.7×10−3, respectively). This suggests that the genetic cause of FH in these unexplained cases is likely to be very heterogeneous, which complicates the diagnostic and novel gene discovery process.
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Affiliation(s)
- Marta Futema
- British Heart Foundation Laboratories, Centre for Cardiovascular Genetics, Institute of Cardiovascular Science, the Rayne Building University College London, London, UK
| | - Vincent Plagnol
- Department of Genetics, Environment and Evolution, UCL Genetics Institute, University College London, London, UK
| | - KaWah Li
- British Heart Foundation Laboratories, Centre for Cardiovascular Genetics, Institute of Cardiovascular Science, the Rayne Building University College London, London, UK
| | - Ros A Whittall
- British Heart Foundation Laboratories, Centre for Cardiovascular Genetics, Institute of Cardiovascular Science, the Rayne Building University College London, London, UK
| | - H Andrew W Neil
- Department of Primary Care Health Sciences, NIHR School of Primary Care Research, University of Oxford, Oxford, UK
| | - Mary Seed
- Department of Cardiology, Imperial College Health Services, Charing Cross Hospital, London, UK
| | | | | | - Sebastiano Calandra
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Colin A Graham
- Queens University Belfast & Regional Genetics Centre, Belfast Health and Social Care Trust/City Hospital Belfast BT9 7AB Northern Ireland UK
| | | | - Fredrik Karpe
- OCDEM, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Oxford, UK
| | - Ronen Durst
- Cardiology Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel Department of Medicine, Center for Research, Prevention and Treatment of Atherosclerosis, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - Eran Leitersdorf
- Department of Medicine, Center for Research, Prevention and Treatment of Atherosclerosis, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - Nicholas Lench
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children, London, UK
| | - Devaki R Nair
- Consultant Lipidologist and Chemical Pathologist Director SAS Laboratory for Cardiac Biomarkers, Royal Free Hospital, London, UK
| | - Handrean Soran
- Cardiovascular Trials Unit, University Department of Medicine, Central Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Frank M Van Bockxmeer
- Division of Laboratory Medicine, Department of Biochemistry, Royal Perth Hospital, Perth, Australia
| | | | - Steve E Humphries
- British Heart Foundation Laboratories, Centre for Cardiovascular Genetics, Institute of Cardiovascular Science, the Rayne Building University College London, London, UK
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28
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Walsh R, Peters NS, Cook SA, Ware JS. Paralogue annotation identifies novel pathogenic variants in patients with Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia. J Med Genet 2013; 51:35-44. [PMID: 24136861 PMCID: PMC3888601 DOI: 10.1136/jmedgenet-2013-101917] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Distinguishing genetic variants that cause disease from variants that are rare but benign is one of the principal challenges in contemporary clinical genetics, particularly as variants are identified at a pace exceeding the capacity of researchers to characterise them functionally. Methods We previously developed a novel method, called paralogue annotation, which accurately and specifically identifies disease-causing missense variants by transferring disease-causing annotations across families of related proteins. Here we refine our approach, and apply it to novel variants found in 2266 patients across two large cohorts with inherited sudden death syndromes, namely catecholaminergic polymorphic ventricular tachycardia (CPVT) or Brugada syndrome (BrS). Results Over one third of the novel non-synonymous variants found in these studies, which would otherwise be reported in a clinical diagnostics setting as ‘variants of unknown significance’, are categorised by our method as likely disease causing (positive predictive value 98.7%). This identified more than 500 new disease loci for BrS and CPVT. Conclusions Our methodology is widely transferable across all human disease genes, with an estimated 150 000 potentially informative annotations in more than 1800 genes. We have developed a web resource that allows researchers and clinicians to annotate variants found in individuals with inherited arrhythmias, comprising a referenced compendium of known missense variants in these genes together with a user-friendly implementation of our approach. This tool will facilitate the interpretation of many novel variants that might otherwise remain unclassified.
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Affiliation(s)
- Roddy Walsh
- NIHR Royal Brompton Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Trust, London, UK
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