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OBJECTIVE Determine if a longitudinal point-of-care ultrasonography (POCUS) elective for medical students is effective in improving POCUS knowledge. METHODS We share the format of our longitudinal POCUS elective for medical students. To evaluate the efficacy of our longitudinal elective, we compare the difference between pre-elective and post-elective scores on a POCUS test using a paired t-test with threshold of statistical significance of p ≤ .05. We also share the results of a post-elective survey evaluating the effectiveness and quality of the longitudinal POCUS elective. RESULTS Pretest mean score was 56.3% (σ = 13.6), while posttest mean score was 73.3% (σ = 9.4), with an average score improvement of 17.0% (95% CI 9.9-24.0%, p < .0001). All students strongly or moderately agreed that they would recommend the elective to future medical students, that they were more confident with their POCUS skills after completing the elective, that the time commitment of the elective was appropriate, and that they felt they had the time to fit the elective into their schedule as a medical school student. Most students (56.7%) strongly or moderately agreed that the knowledge gained from the POCUS elective had helped them in their clinical rotations. CONCLUSIONS Our longitudinal POCUS curriculum subjectively and objectively improves medical students’ POCUS knowledge while remaining accessible to students. We share our unique longitudinal POCUS elective curriculum, the format of which and its benefits are transferable to other medical schools. Through this, we hope to provide others with ideas on how they may implement a longitudinal POCUS elective.

ABSTRACTBackgroundAlternate complement dysregulation postrenal transplantation can result in thrombotic microangiopathy (TMA). There is a scarcity of data regarding outcomes based on the timing of TMA post‐transplant, coupled with a lack of follow‐up biopsy findings post TMA diagnosis. This study aims to assess allograft and patient outcomes in individuals developing early TMA, defined within 4 months post‐transplantation, and explore any differences in follow‐up surveillance biopsies compared to a non‐TMA group.DesignThis is a single center retrospective study between January 1, 2002 and October 10, 2019. Patients who developed TMA within 4 months post‐transplantation were compared to a propensity matched non‐TMA group.ResultsThirty‐one patients developed TMA within 4 months of renal transplantation. Index TMA biopsy featured noticeable glomerular, and vascular lesions along with acute tubular injury. Four‐month surveillance biopsy showed significant glomerulitis, transplant glomerulopathy and chronic interstitial fibrosis as compared to non‐TMA group. However, at 1 year, these differences were no longer significant. There was no significant difference in patient survival (TMA vs. non‐TMA,p = 0.083); however, death censored graft survival was significantly lower in the TMA group (p < 0.001). TMA patients had a significantly lower estimated glomerular filtration rate at 4 months and at 1 year as compared to the non‐TMA group.ConclusionEarly onset TMA post renal transplant leads to decreased renal function and lower graft survival. Early recognition and prompt treatment may help in reducing the adverse outcomes.

Insulin is a key regulator of amino acid metabolism. Many plasma amino acids, including lysine and its metabolite, α-aminoadipic acid (α-AA), a predictor for developing diabetes, are elevated in insulin resistance (IR). In 18 overweight women with IR and polycystic ovary syndrome compared with 12 lean control women, high physiological insulin during a euglycemic clamp failed to normalize many elevated amino acid metabolites, including branched-chain and aromatic amino acids, α-aminobutyric acid, and lysine, but normalized α-AA. To understand the underpinnings of differential responses of lysine and its metabolic product α-AA to high physiological insulin in IR compared with control participants, we developed a kinetic model using [α-15N1]-lysine and [13C1]-α-AA as tracers and measured the two tracers simultaneously in α-AA by innovative mass spectrometry. High insulin increased lysine conversion to α-AA in the IR and control groups but failed to normalize plasma lysine concentrations in IR due to a decrease in lysine metabolic clearance rate (MCR). In contrast, despite higher conversion rates of lysine to α-AA by high insulin, α-AA concentration decreased in IR because of the sustained greater MCR of α-AA. The abnormal amino acids and metabolites, even while on high physiological insulin, could potentially explain many functional derangements in IR. Article Highlights

AbstractPupillary changes can be an important semiologic feature in focal epilepsy. Though the subcortical networks involving pupillomotor function have been described, cortical generators of pupillary dilation and constriction in humans are not well known. In this report, we describe a case of pupillary constriction occurring during seizures in a patient with drug resistant focal epilepsy. On stereoelectroencephalography, onset was noted within the posterior segment of the right intraparietal sulcus and direct cortical electrical stimulation of these electrode contacts reproduced pupillary constriction associated with habitual seizures. This is the first case report to describe ictal pupillary constriction during SEEG with confirmation of the cortical localization by direct cortical electrical stimulation. The posterior segment of the right intraparietal sulcus localization of pupillary constriction may aid in surgical evaluation patients with drug resistant focal epilepsy.

Abstract Background Ventriculoperitoneal (VP) shunt is still a mainstay of treatment in centers for infants with aqueductal stenosis which is the most common cause of congenital obstructive hydrocephalus. Shunt migration remains a common complication. Delayed distal shunt tip migration into the thoracic cavity due to negative intrathoracic pressure is a rare occurrence. Case Presentation Authors report a 1-year-old infant presenting with drowsy sensorium, increasing head circumference, and bulging anterior fontanelle. Magnetic resonance imaging of the brain revealed significant obstructive hydrocephalus with periventricular seepage. A large expansile diverticulum of the suprapineal recess extending infratentorially compressing the dorsal midbrain and cerebellum inferiorly. The child underwent an emergency right-side VP shunt (medium pressure) in view of clinical symptoms of raised intracranial pressure. A right iliac fossa infraumbilical transverse incision was taken for placing the abdominal end. Visual confirmation of bowel was done after opening the peritoneum by two operating surgeons prior to inserting the distal catheter. Postoperative course was uneventful. The child presented 3 months later with acute dyspnea and diminished breath sounds on the right hemithorax. Neurologically, the child was active, feeding well, and anterior fontanelle was lax. A chest roentgenogram and computed tomogram (CT) of the thorax revealed complete shunt migration into the pleural space with significant pleural effusion on the right side. The distal shunt system on CT appeared to enter the pleural space below the 8th rib, probably indicating that there was subcostal tunneling of the shunt below the 8th rib space during the first surgery which was inconspicuous and subsequently over a span of 3 months due to sucking effect of negative intrathoracic pressure the shunt gradually migrated into the pleural cavity which led to the effusion. An emergency VP shunt revision was performed. The distal end below the chamber was retunneled subcutaneously into a new incision in the left paraumbilical region. Postoperative chest and abdomen roentgenograms showed resolving effusion and accurate shunt placement. The child required elective ventilation temporarily to tide over the underlying lung collapse and an intercostal tube drainage for the cerebrospinal fluid (CSF) hydrothorax for 2 days to aid in quicker weaning. The child was discharged on the 5th postoperative day. Discussion Intrapleural migration of VP shunts has been contemplated to be due to trauma during surgery, migration across foramen of Bochdalek or Morgagni, and negative intrathoracic pressure. Taub and Lavyne have classified thoracic complications of VP shunt as thoracic trauma during shunt tunneling, supradiaphragmatic migration of shunt or transdiaphragmatic migration of shunt, and pleural effusion complicated by CSF ascites. Transdiaphragmatic migration is commonly seen in pediatric population and supradiaphragmatic migration can be seen in any age group. We believe our case to be a type of supradiaphragmatic migration of the shunt which has occurred slowly over a span of time due to the negative intrathoracic pressure. The idea behind this clinical case image is to edify neurosurgeons, pediatricians, and intensivists to remain wary of such a complication.

BACKGROUND AND OBJECTIVES: Health care providers' exposure to global surgical disparities is limited in current nursing and/or medical school curricula. For instance, global health is often associated with infectious diseases or maternal health without acknowledging the growing need for surgical care in low- and middle-income countries (LMICs). We propose an international virtual hackathon based on neurosurgical patient cases in under-resourced settings as an educational tool to bring awareness to global surgical disparities and develop relationships among trainees in different countries. METHODS: Participants were recruited through email listservs, a social media campaign, and prize offerings. A 3-day virtual hackathon event was administered, which included workshops, mentorship, keynote panels, and pitch presentations to judges. Participants were presented with real patient cases and directed to solve a barrier to their care. Surveys assessed participants' backgrounds and event experience. The hackathon was executed through Zoom at Harvard Innovation Lab in Boston, MA, on March 25 to 27, 2022. Participants included medical students, with additional participants from business, engineering, or current health care workers. RESULTS: Three hundred seven applications were submitted for 100 spots. Participants included medical students, physicians, nurses, engineers, entrepreneurs, and undergraduates representing 25 countries and 82 cities. Fifty-one participants previously met a neurosurgeon, while 39 previously met a global health expert, with no difference between LMIC and high-income countries' respondents. Teams spent an average of 2.75 hours working with mentors, and 88% of postevent respondents said the event was “very” or “extremely conducive” to networking. Projects fell into 4 categories: access, language barriers, education and training, and resources. The winning team, which was interdisciplinary and international, developed an application that analyzes patient anatomy while performing physical therapy to facilitate remote care and clinical decision-making. CONCLUSION: An international virtual hackathon can be an educational tool to increase innovative ideas to address surgical disparities in LMICs and establish early collaborative relationships with medical trainees from different countries.