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Medical Image of the Week: Mediastinal Lipomatosis

By: Borg B, Knepler J

Abstract: No abstract available. Article truncated after 150 words. A 61-year-old man presented to the pulmonary clinic for evaluation of a chronic cough of 6 months’ duration.  Other medical problems included class three obesity, obstructive sleep apnea on CPAP therapy, and hypertension.  Chest X-Ray (Figure 1) revealed a right mediastinal mass which then prompted a chest CT to be performed. The chest CT (Figure 2) demonstrated a homogenously enhancing, well circumscribed and fat-attenuating 8 x 5 cm mass in the right paratracheal region without invasion or compression into surrounding structures.

Mediastinal lipomatosis was diagnosed.  This is a benign soft tissue tumor made of mature adipocytes that can be seen with obesity, chronic corticosteroid use, and Cushing’s syndrome.  They are thought to represent up to 2.3% of all primary mediastinal tumors (1).  They are occasionally associated with compression of surrounding structures which can cause superior vena cava syndrome, dry cough, dysphagia, and occasionally arrhythmias (2).  Management is typically conservative with …



Medical Image of the Week: Dobhoff Tube Placement with Roux-En-Y Gastric Bypass

By: Ali H, Ateeli H, Natt B, Chaudhary S

Abstract: No abstract available. Article truncated after 150 words. Roux-en-Y gastric bypass is one of the most commonly performed bariatric operations in the United States.  It involves partitioning a small gastric pouch off the proximal stomach and attaching that pouch directly to the intestine, thereby bypassing the large remainder of the stomach (1,2). Placing a Dobhoff tube (DHT) and confirming its placement can be challenging due to the change in anatomy after the procedure. Here, we have a 65-year-old woman who presented to the hospital with acute encephalopathy and acute hypoxic respiratory failure due to multifocal pneumonia requiring intubation and prolonged ICU stay. A DHT was inserted after intubation for feeding purposes. An abdominal X-ray was obtained to confirm placement of the DHT (Figure 1).  Normally the DHT tip should be placed in the 2nd to 3rd portion of the duodenum and would create a C-shaped tracing on the X-ray. However, in our patient who had history of Roux-en-Y …



Medical Image of the Week: Atypical Deep Sulcus Sign

By: Ali H, Ateeli H, Natt B, Chaudhary S

Abstract: No abstract available. Article truncated 150 words. The deep sulcus sign is a radiolucent lateral sulcus where the chest wall meets the diaphragm. The costophrenic angle is abnormally deepened when the pleural air collects laterally, producing the deep sulcus sign (1). Here, we present a 42-year-old man with a history of asthma who was admitted with status asthmaticus requiring intubation. On hospital day 3, the patient developed subcutaneous emphysema surrounding his entire neck and extending into left side of the chest wall. Chest X-ray after this episode showed an atypical deep sulcus sign (Figure 2) concerning for left sided pneumothorax that was also confirmed by bedside ultrasound. A surgical chest tube was placed immediately and a repeat chest X-ray (Figure 3) showed complete resolution of the pneumothorax and the deep sulcus sign. In critically ill patients where it is difficult to obtain an upright film, it is important to pay attention to the costophrenic angles when concern …



Airway Registry and Training Curriculum Improve Intubation Outcomes in the Intensive Care Unit

By: Malo J, Hypes C, Natt B, Cristan E, Greenberg J, Morrissette K, Snyder L, Knepler J, Sakles J, Knox K, Mosier J


Background: Intubation in critically ill patients remains a highly morbid procedure, and the optimal approach is unclear. We sought to improve the safety of intubation by implementing a simulation curriculum and monitoring performance with an airway registry.

Methods and Methods: This is a prospective, single-center observational study of all intubations performed by the medical intensive care unit (ICU) team over a five-year period. All fellows take part in a simulation curriculum to improve airway management performance and minimize complications. An airway registry form is completed immediately after each intubation to capture relevant patient, operator, and procedural data.

Results: Over a five-year period, the medical ICU team performed 1411 intubations. From Year 1 to Year 5, there were significant increases in first-attempt success (72.6 vs. 88.0%, p<0.001), use of video laryngoscopy (72.3 vs. 93.5%, p<0.001), and use of neuromuscular blocking agents (73.5 vs. 88.4%, p<0.001). There were concurrent decreases in rates of desaturation (25.6 vs. 17.1%, p=0.01) and esophageal intubations (5 vs. 1%, p=0.009). Low rates of hypotension (8.3%) and cardiac arrest (0.6%) were also observed.

Conclusions: The safety of intubation in critically ill patients can be markedly improved through joint implementation of an airway registry and simulation curriculum.




Social Media: A Novel Engagement Tool for Miners in Rural New Mexico

By: Wigh S, Jarrell WC, Kocher E, Karr R, Wang X, Sood A

Abstract: Background: New Mexico miners usually live in rural areas. As compared to urban areas, rural areas in the United States demonstrate a lower use of the Internet and lower adoption of new technologies such as the smartphone and social media. Our study objective was to examine the use of these technologies among miners in rural New Mexico. Our long-term goal is to utilize these technologies to increase our program’s engagement with miners to provide medical screening and education services. Methods: We anonymously surveyed 212 miners at two town hall meetings in rural New Mexico communities, predominantly Hispanic and American Indian, in 2017. We then compiled that data in a Research Electronic Data Capture (REDCap) database and performed a statistical analysis using Statistical Analysis Software (SAS). IRB approval was obtained. Results: 60.8% of the 212 surveyed miners reported using social media. Among social media users, 88.4% reported using Facebook.  Most miners expressed willingness to use social media to keep in contact with other miners (51.2% overall) or to receive information about our miners’ program services (53.9% overall); and social media users were more likely to do so than non-users (p<0.001 for both analyses). Additionally, 79.7% of miners who owned a smartphone utilized it for texting. Conclusions: A majority of miners in rural New Mexico report use of social media and express willingness to use social media to network with other miners and with our program. The adoption of these communication technologies by rural New Mexico miners in our study is comparable or superior to that reported by rural Americans overall. It is possible to utilize this newer technology to increase program engagement with miners.