Deep vein thrombosis is a common condition encounter by hospitalists and managed by either oral or intravenous anti-coagulation. Although uncommon, phlegmasia cerulea dolens (PCD) is a life-threatening manifestation of acute deep vein thrombosis requiring early recognition and aggressive intervention to preserve life and limb. PCD is characterized by marked swelling of the lower extremities with pain and cyanosis, which often leads to gangrene and amputation. We present the case of a patient who developed PCD of her left lower extremity who was successfully treated with an EkoSonic™ endovascular catheter (Boston Scientific, Marlborough, MA, USA), which accelerates lytic dispersion of the thrombolytic drug through ultrasound technology.

In burned patients, inhalation injury can result in progressive pulmonary dysfunction, infection, and death. Although bronchoscopy is the standard for diagnosis, it only assesses the proximal airway and does not provide a comprehensive analysis of pulmonary insult. Chest radiographs have not been proven helpful in diagnosis of inhalation injury. Our hypothesis is that a CT scan alone or in conjunction with bronchoscopy can be used as a prognostic tool for critically ill burn patients, especially those with inhalation injury. The authors performed a retrospective study of all patients admitted to the U.S. Army Institute of Surgical Research Burn Center between 2002 and 2008 with chest CT within 24 hours of admission. They divided subjects into two groups, those with evidence of inhalation injury on bronchoscopy and those without. They used a radiologist's score to assess the degree of damage to the pulmonary parenchyma. The primary endpoint was a composite of pneumonia, acute lung injury/acute respiratory distress syndrome, and death. The inhalation injury group consisted of 25 patients and the noninhalation injury group of 19 patients. Groups were not different in age, TBSA burned, and percentage full-thickness burn. By multiple logistic regression, detection of inhalation injury on bronchoscopy was associated with an 8.3-fold increase in the composite endpoint. The combination of inhalation injury on bronchoscopy and a high radiologist's score was associated with a 12.7-fold increase in the incidence of the composite endpoint. Admission CT assists in predicting future lung dysfunction in burn patients.

Internal medicine residents across all post-graduate year (PGY) levels at our institution lacked confidence to independently perform core internal medicine procedures. Utilizing simulation-based medical education as an adjunct to clinical training is well accepted by internal medicine trainees, and resulted in significantly improved procedural confidence. This intervention was well received by trainees and could feasibly be replicated at other active-duty military internal medicine residency programs to assist with readiness. Research is currently in progress to correlate in-situ competency and evaluate clinical outcomes of this improved confidence.

BACKGROUND: Obstructive lung disease is diagnosed by a decreased ratio of FEV 1 to the vital capacity (VC). Although the most commonly used VC is FVC, American Thoracic Society guidelines suggest alternative VCs, for example, slow VC (SVC), may offer a more-accurate evaluation of breathing capacity. There is recent evidence that using only FEV 1 /FVC underrecognizes obstruction in subjects at high risk and who are symptomatic. Previous studies have indicated that healthy individuals show a minimum difference between FVC and SVC; however, testing of individuals with asthma and who are symptomatic indicates that SVC can be markedly larger than FVC. OBJECTIVE: To evaluate the differences among SVC, FVC, and SVC-based measurements in the diagnosis of symptomatic obstructive lung disease. METHODS: A retrospective analysis was performed of spirometry and plethysmography measurements from studies conducted between 2011 to 2015. We established a pulmonary function database that incorporated predictive equations from the National Health and Nutrition Examination Survey III (NHANES III). The SVC to FVC difference was calculated. FEV 1 /SVC was compared with FEV 1 /FVC by using NHANES III lower limit of normal values. RESULTS: A total of 2,710 studies with 2,244 subjects were reviewed. Spirometric obstruction, as defined by NHANES III, was identified in 26.1% of the studies (707/ 2,710). The mean (؎ SD) difference between SVC and FVC was 375.0 ؎ 623.0 mL and 258.8 ؎ 532.5 mL in those with and those without obstruction, respectively. Subgroup and multivariate analysis demonstrated age, body mass index, and FEV 1 associated contributions to the difference between SVC and FVC. By using FEV 1 /SVC, the prevalence of obstruction increased from 26.1 to 45.0% (1,219/2,710) and identified 566 additional studies of subjects with obstruction. Fifty-four percent of the subjects with newly-identified obstructive lung disease (305/566) had smoking histories, and 67.4% (345/512) received medications for obstructive lung disease. CONCLUSIONS: The isolated use of FVC-based diagnostic algorithms did not recognize individuals with symptomatic obstructive lung disease. Recognizing the difference between SVC and FVC measurements in subjects will improve testing and diagnosis of obstructive lung disease.