Initial Laboratory Research Articles

BABESIA MICROTI INFECTION WITH LOW-GRADE PARASITEMIA CAUSING ARDS IN AN IMMUNOCOMPETENT PATIENT

BABESIA MICROTI INFECTION WITH LOW-GRADE PARASITEMIA CAUSING ARDS IN AN IMMUNOCOMPETENT PATIENT

S2740 Incidentally Discovered Cryptogenic Cirrhosis in a Patient With Untreated Celiac Disease

Introduction: Celiac disease is an autoimmune enteropathy that affects around 1% of the general population and primarily manifests its effects on the small bowel. However, the systemic nature of this condition, especially regarding the liver, has been gaining some recognition in the literature. Mild liver disease is common, but few cases progress to cirrhotic liver disease. In this case report, cryptogenic cirrhosis was incidentally discovered in a patient with a long history of untreated celiac disease with no evidence of any other underlying cause for the cirrhosis. Case Description/Methods: A 78-year-old male with past medical history of longstanding celiac disease, atrial fibrillation, CHF, T2DM, CKD III, and thoracic aortic aneurysm underwent a CT scan for thoracic aortic aneurysm surveillance. Incidentally, on CT scan, a 1.2 cm enhancing focus in left hepatic lobe, cirrhotic liver morphology, and sclerosing mesenteritis were discovered. Initial lab work-up was remarkable for an elevated alkaline phosphatase of 171 and initial tissue transglutaminase (TTG) was >100. Confirmatory ultrasound showed a liver with heterogeneous echotexture, 1.2cm cyst on the left hepatic lobe, and patent main portal vein. Further laboratory workup showed negative anti-smooth muscle antibody, negative antimitochondrial antibody, negative liver kidney microsomal antibody, and alpha-fetoprotein < 2. Patient reported a history of constipation but denied any other gastrointestinal symptoms, including abdominal pain, hematochezia, diarrhea, nausea, or vomiting. Patient had a remote history of alcohol use, with only occasional recreational use at presentation. The patient had never followed a gluten-free diet. (Figure) Discussion: Celiac disease is now thought to be a systemic condition, with up to 30% of patients displaying extraintestinal manifestations. Multiple studies have shown an increased incidence of celiac disease in patients with cirrhosis, and that cessation of gluten can improve not only the small bowel, but also liver function. This suggests that there is utility in monitoring liver function in patients with celiac disease and screening patients with cirrhosis for celiac disease on initial workup. It is also important to inform patients of these connections, as compliance with a gluten-free diet may prevent the progression of the enteropathy and protect its systemic targets.Figure 1.: Sagittal View of Cirrhotic Liver Morphology on Right Upper Quadrant Ultrasound.

S2361 Pancreatic Protrusion: A Rare Case of Grade IV Hiatal Hernia With Complete Pancreatic Herniation

Introduction: Hiatal hernias are commonly described as herniation of abdominal contents through the esophageal hiatus of the diaphragm. With this, classification systems exist to define hernias as either sliding or type one, or to consider types 2, 3 and 4 as paraesophageal which also present with other sequelae. While most commonly, hiatal hernias are type one and less severe in nature, 5 percent of cases become more involved and severe. The current prevalence of hernias ranges between 10 to 80 percent of North Americans. In this case, we shed light on the diagnosis and imaging of a rare sequelae of hiatal hernia which included not only small and large protrusion, but also herniation of the pancreas. Case Description/Methods: The patient is a 95 year old woman with a past medical history of abdominal aortic aneurysm as well as a large hiatal hernia presenting with a chief complaint of poor oral intake over the last several days prior to presentation. The patient was found to be significantly lethargic compared to baseline and reported decreased oral intake due to discomfort after eating. The patient’s initial vitals demonstrated a mild tachycardia with initial lab findings within normal ranges. A CT chest and abdomen was performed which demonstrated a large hiatal hernia, which now contained loops of small and large bowel as well as the pancreas. During the hospital course, interdisciplinary rounds were conducted in regards to the patient case with surgical and gastroenterology recommendations. The uniqueness of presentation of pancreatic protrusion was discussed as well as the current treatment and monitoring modalities of a Grade 4 hiatal hernia, now presenting with complications. Ultimately, the discussions were conducted with the patient who reported she was most amenable to comfort focused care with a pleasure based diet in an attempt to avoid any medical and surgical intervention. Discussion: In emergent cases, such as with respiratory distress and bowel strangulation, emergent surgical intervention is considered in cases of hiatal hernia. However, lesser defined and established are the findings and management as well as treatment modalities of more severe hernias involving protrusion of pancreatic contents. Here, we add to imaging the unique presentation of a common diagnosis with rare sequelae. We also hope to add to a growing body of literature on the imaging, and potential stepwise approach to management of type 4 hiatal hernias with severe and emergent treatment considerations.

S3312 Acute Decompensation of Late-Onset Glutaric Acidemia Type II in the Setting of Multifactorial Cirrhosis

Introduction: Glutaric acidemia type 2 (GA2), or multiple acyl CoA dehydrogenase deficiency (MADD), is a disorder of fatty acid oxidation, amino acid and choline metabolism. GA2 is inherited in an autosomal recessive manner by changes in the ETFA, ETFB, or ETFDH genes. The classic and most severe form of GA2 is neonatal onset. Our patient has symptoms of late onset disease, including fatigue, vomiting, episodic hyperammonemia, fatty infiltration of the liver, and an absence of congenital malformations. In acute decompensations, triggered by catabolism and/or intercurrent illness, individuals with GA2 may develop metabolic acidosis, rhabdomyolysis, elevation of transaminases, and hyperammonemia. Case Description/Methods: This case describes a 36-year-old gentleman with late onset glutaric acidemia type II, multifactorial cirrhosis from non-alcoholic steatohepatitis in the setting of a metabolic disorder, class III obesity, alcoholic associated liver disease, portal hypertension, splenic embolization, CHF, presented to the ED for confusion following progressive nausea and vomiting over five days, and was found to have elevated ammonia level at 165 mcmol/L. His vital signs were tachycardia of 133 bpm, hypertension of 221/133, he was afebrile in no respiratory distress. Physical exam was notable for a drowsy obese male oriented to self and place, diaphoretic, tachycardic, no JVD, no crackles, non-tender abdomen with normoactive bowel sounds, and asterixis. Initial lab studies were significant for platelets of 131k, potassium of 2.4 mmol/L, total bilirubin 3.7 mg/dL, AST 355 ALT 130 ALP 143 IU/L, and no detectable ethanol, acetaminophen or salicylates. Multiple factors can influence his ammonia level, including underlying cirrhosis and glutaric acidemia. His metabolic crisis was suspected due to a catabolic state from intake of high-protein diet, and was managed with 10% Dextrose IV fluids, levocarnitine, riboflavin, lactulose, low-protein low-fat diet with improvement in encephalopathy. Hypokalemia from decreased absorption and lactulose use resolved with potassium supplements and addition of spironolactone. Discussion: Metabolic disorders are rare but important to consider in patients that present with metabolic crisis. They can decompensate after periods of dehydration, exercise, alcohol ingestion or illnesses and develop hyperammonemia, transaminitis, metabolic acidosis. These individuals have a lifelong risk of intermittent episodes of metabolic crisis and prompt management is imperative to recovery.

UNCOMMON CAUSES OF RECURRENT UNILATERAL PLEURAL EFFUSIONS

UNCOMMON CAUSES OF RECURRENT UNILATERAL PLEURAL EFFUSIONS

S3195 The Liver and Cryoglobulinemia: A Relationship Beyond Hepatitis C

Introduction: Cryoglobulinemia is a small and medium vessel vasculitis with varied clinical manifestations. The most common etiology is hepatitis C virus. Other hepatotropic viruses, including hepatitis A, have been rarely associated with very few cases reported. Here we present a unique case of cryoglobulinemia associated with hepatitis A. Case Description/Methods: A 58-year-old female presented to the Emergency Department (ED) with bloating, abdominal pain, and fullness for about a week. She has a past medical history of diabetes mellitus type II, hypothyroidism, and hypertension. She was afebrile and hemodynamically stable in the ED with Initial lab workup showing AST/ALT of 5228/4792, total bilirubin of 7.9 with a direct bilirubin of 6.1. Further workup showed positivity for hepatitis A, including IgM and positive type II cryoglobulins. The rest of the autoimmune workup was negative for rheumatoid factor, ANA, SS/Ro, SS/La, anti-smooth muscle antibody, and anti-mitochondrial antibody. She also had acute renal failure requiring hemodialysis. Management included supportive therapy with significant improvement in her symptoms. Discussion: Cryoglobulinemia is a condition where abnormal immunoglobulins precipitate in serum at temperatures below 37C. They can deposit in blood vessels and cause obstruction or vasculitis, with involvement of various organs. Type I cryoglobulinemia is usually associated with hematologic malignancies whereas mixed cryoglobulinemia (type II, III) is associated with hepatitis C and rarely seen with hepatitis A. Very few cases showing an interrelation between hepatitis A and cryoglobulinemia have been reported in the literature making this a rare association. Hence, more studies need to be done to investigate extrahepatic features of hepatitis A.

Non-traumatic Spontaneous Spinal Subdural Hematoma in a Patient with Acute Paraplegia

Acute non-traumatic spinal subdural hematoma (SSDH) is a rare clinical condition in the emergency medicine practice and difficult to diagnose during the primary physical examination. It mostly occurs at thoracal vertebra levels due to trauma, use of anticoagulants, medical procedures such as acupuncture, arteriovenous malformations, hematological disorders or space-occupying lesions. Here, we discussed an elderly female patient who was not on anticoagulant and described sudden loss of muscle strength and sensation in both lower extremities. Initial laboratory and imaging including brain computerized tomography (CT) and magnetic resonance imaging (MRI) were in normal range. Her secondary examination revealed anesthesia under the T4 dermatome level. Cervical spine-MRI imaging revealed a subdural hematoma significantly compressing the spinal cord on the C7-T1 dermatome segments. Any emergency neurosurgical intervention was not considered and the patient was interned in the neurosurgical clinic for conservative treatment and further examination. Patient , with no progress seen in consecutive MRI scans, was discharged after offering an outpatient check-up. We recommend secondary physical examination in emergency department (ED). In the case of appearance of sensory deficits of certain dermatomes, spine-MR imaging may lead to put the diagnose early in ED.

CORRELATION OF CLINICAL RISK SCORES WITH ANGIOGRAPHIC EXTENT AND SEVERITY USING MODIFIED GENSINI SCORE IN PATIENTS WITH ST ELEVATED MYOCARDIAL INFARCTION

Cardiovascular diseases have emerged as a significant health burden and became a leading cause of mortality in developing countries like India.In cardiovascular diseases, acute coronary syndromes are the primary cause of morbidity and mortality, for which timely diagnosis and appropriate therapy are of foremost importance to improve clinical outcomes.Different scoring systems are now available based on initial clinical history, electrocardiographic and laboratory tests that enable early risk stratification on admission. The risk scores were created and recommended by national and international guidelines to identify patients with a higher probability of adverse events, recommending more intensive treatment and early angiography in this population.In this study, we considered evaluating clinical predictors and suitable risk scores GRACE and TIMI that correlate with the severity of angiographic extent of coronary artery disease in patients presenting with ST-elevation myocardial infarction using Modified GENSINI score.

The Importance of Hyperthyroid Screening in Acute Decompensated Heart Failure with Persistent Tachycardia Despite Optimal Decongestion: A Case Report

Background: Hyperthyroid has various effects on the cardiovascular system. Cardiac arrhythmias ranging from sinus tachycardia to atrial fibrillation and low/high cardiac output state to congestive heart failure are observed in patients with hyperthyroidism. If hyperthyroidism is recognized and treated early, the cardiac dysfunction could be corrected. This case presentation will discuss the importance of thyroid function screening.&#x0D; Case Illustration and Discussion: A man was admitted to the emergency department with signs and symptoms of acute decompensated heart failure. Further examination was performed to confirm the diagnosis, namely ECG, laboratory examination including thyroid function test, and echocardiography. During hospitalization, heart failure medication was given and up titrated. The patient was still tachycardia until hyperthyroid was corrected with anti-thyroid medicines.&#x0D; Conclusion: Hyperthyroidism can cause or worsen left ventricular dysfunction, especially in individuals with a history of cardiovascular disease. Thus, thyroid function tests should be assessed during initial laboratory examination, especially on patients with acute decompensated heart failure.

Measurement-While-Milling (MWM): An innovative approach for increasing the casing milling efficiency in deep drilling operations

Deep boreholes are secured by steel tubes (casings) which are run in the hole and cemented in place. In most cases, these casings are considered a permanent installation. However, sometimes they have to be removed in order to repair or abandon the well. As the casing is cemented in place, it cannot be pulled, but needs to be milled to small chips which are flushed out of the borehole by the drilling mud. One of the main challenges in casing milling operations is continuous and complete chip removal. If the metal chips are too long, chip nests will grow around the milling string. As a result, this will restrict the annulus flow area and affect the chip removal in boreholes. The obvious solution in such condition is to do round tripping and clean the chip nest which is associated with the risk of injuries, as well as, increasing the none-productive time. In the worst case, the poor cleaning and circulation of chips can even end up with the milling string stucking problem in boreholes, consequently long-time fishing job. According to the available literatures, hardly any study for identifying the chip shapes and accordingly adapting the operation parameters to the casing milling process environment downhole to keep milling within desired generated chip shapes and sizes could be found. This paper presents an encouraging idea to monitor the milling process in real time by utilizing the acoustic emission signals (vibration modes) accompanied with the milling process to identify the desired chip shape and size range. Initial laboratory tests have been carried out to investigate and study the acoustic emission signals accompanying the casing milling process to identify the chip shapes and sizes. The preliminary test results show very good correlation and agreement between the chip length formed during those specific tests and the observed burst events in the measured signals. The study results have demonstrated the functionality of the new concept, and thus confirmed that it is a very promising idea towards developing a practical real time downhole monitoring system for milling operations. Adapting the milling operation parameters downhole in real time to keep the milling process within the desired generated chip shapes and sizes will offer better cleaning and removal of the chips and will prevent the development of chip nest around the drill string and its consequences such as round tripping, risk of drilling crew injury, none-productive time and even milling string stucking problems.

57-Year-Old Man With Headache, Vomiting, and Gait Instability

57-Year-Old Man With Headache, Vomiting, and Gait Instability

Using laboratory parameters as predictors for the severity and mortality of COVID-19 in hospitalized patients.

The aim of this study was to explore association of initial laboratory parameters of hospitalized patients with COVID-19, with the severity and death incident. In this retrospective study, patients were classified based on mortality outcome (survivor and non-survivor) and disease severity (non-severe, severe, and critical). The initial laboratory data (within the first two days of hospital admission) were compared between these categories. Of 362 COVID-19 patients hospitalized between January-2021 and May-2021, 39.0% were non-severe, 32.2% severe, and 28.7% critical. 77.3% were lived and 22.7% died in hospital. Non-survivors were significantly older than survivors. There was a statistically significant association between exceeding the cut-points of laboratory parameters and the severity of the disease or even death. These laboratory parameters included D-dimer, C-reactive protein, prothrombin time, ferritin, white blood cells, neutrophil count, aspartate aminotransferase, creatinine, blood urea nitrogen, lymphocyte count, and albumin. Also, exceeding the cut-points of these parameters showed high odds of death. The highest odds ratio was reported for albumin <3.5 g/dL (OR=14.318 [4.784-42.851], p<0.001). The cut-points of the laboratory parameters could effectively be used as predictors to assess the severity and risk of death to improve the management of COVID-19 patients.

Cryoglobulinaemia in a Thoroughbred gelding with multicentric lymphoma

SummaryA 17‐year‐old Thoroughbred gelding was presented to the hospital with epistaxis, multiple alopecic skin lesions, firm swelling in the masseter region and acute cellulitis of the right hind distal limb. Epistaxis originated from ulcerative lesions within the nasal passages and nasopharynx. Histopathology results of a skin biopsy revealed necrotising dermatitis. Initial laboratory evaluation included severe leucocytosis with marked hyperproteinaemia and adequate coagulation times. A cryoprecipitate was noted in a refrigerated blood sample in the absence of lipemia. Serum protein electrophoresis yielded inconsistent results depending on sample preparation, suggestive of the presence of cryoglobulins. Evaluation of an uncentrifuged sample revealed a gammopathy, with a peak in the beta 2 globulin fraction. Treatment for vasculitis and dermatitis resulted in little clinical improvement, and the gelding was euthanised. Necropsy revealed multicentric lymphoma with a tropism for perivascular spaces and skeletal muscles.

6-Year-Old Male Drowning Complicated by Cardiac Arrest and Ensuing Metabolic and Respiratory Acidosis: Should Presence of Pulses Lead Clinicians to Pursue Prolonged Cardiopulmonary Resuscitation?

BackgroundDrowning is one of the leading causes of death in the pediatric population. Patients arriving to the emergency department (ED) with submersion injuries are often asymptomatic and well-appearing, but can sometimes present critically ill and require prolonged resuscitation. The question of how long to continue resuscitation of a pediatric patient with a submersion injury is a difficult question to answer. Case ReportWe present a case of 6-year-old boy was found by his friends submerged in sea water for 10–15 min. The patient was rescued by lifeguards and evaluated by emergency medical personnel, who found him breathing spontaneously but unresponsive. En route to hospital, the patient became apneic, cardiopulmonary resuscitation (CPR) was started, and the patient was intubated. The patient arrived to the ED in cardiopulmonary arrest, CPR was continued and epinephrine was administered. Return of spontaneous circulation was achieved after 42 min in the ED. Initial laboratory test results showed severe acidosis and chest x-ray study showed diffuse interstitial edema. Ventilator settings were adjusted in accordance with lung protective ventilation strategies and the acidosis began to improve. Over the next several days, the patient was weaned to noninvasive ventilation modalities and eventually made a complete neurologic recovery and continued to be a straight-A student.Why Should an Emergency Physician Be Aware of This?We make the case that, in select drowning patients, duration of CPR longer than 30 min can potentially result in favorable neurologic outcomes. Prolonged CPR should be especially strongly considered in patients with a pulse at any point during evaluation. With the combination of prolonged CPR and judicious use of lung protective mechanical ventilation strategies, we were able to successfully treat the patient in our case.

Abstract P119: Severe Paroxysmal Hypertension In Patient With Gastric Neuroendocrine Tumor Detected By PET Dotatate Imaging

Neuroendocrine tumors (NET) are rare neoplasms originating from neuroendocrine cells in the endocrine, gastrointestinal, or bronchopulmonary systems. When symptomatic, patients may present with paroxysmal HTN. A 51-year-old woman with CAD and prior CABG presented to the hospital with sudden onset headache and BP in the 200s/90s. Her physical exam was unremarkable. ECG showed new T wave inversions in leads V1 and V2 and high-sensitivity troponin was elevated at 1827 ng/L. CT angiography of her head and neck was normal. Her HTN improved with IV labetalol and pain control. We admitted her for BP control and secondary HTN evaluation. Initial lab findings were unremarkable (see table). A renal artery ultrasound showed no renal artery stenosis. CT of her chest, abdomen, and pelvis showed no evidence of NET. She continued to have paroxysms of severe HTN, initially controlled with IV medications, then transitioned to an oral four-drug regimen prior to discharge. Fractionated plasma metanephrines and catecholamines, and 24-hour urine fractional metanephrines were obtained (results pending at time of discharge).Follow up testing showed elevated urinary metanephrines and Chromogranin levels (see table), suggestive of NET. A Ga-68 PET-DOTATE scan showed a focus of increased activity in the anterior stomach. Endoscopy revealed a gastric body lesion, identified as grade 2, well-differentiated NET on biopsy. The patient underwent laparoscopic wedge gastrectomy with clear margins. Her headaches resolved, and BP improved. This case demonstrates the utility of Ga-68 PET DOTATE imaging in determining the presence of NET, not detected by CT images, as the reason for severe, paroxysmal HTN.

What’s the difference between lung adenocarcinoma and lung squamous cell carcinoma? Evidence from a retrospective analysis in a cohort of Chinese patients

BackgroundLung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC) are the two most common subtypes of lung cancer. Previously, they were categorized into one histological subtype known as non-small cell lung cancer (NSCLC) and often treated similarly. However, increasing evidence suggested that LUAD and LUSC should be classified and treated as different cancers. But yet, detailed differences in clinical features between LUAD and LUSC have not been well described.MethodsA cohort of 142 Chinese patients with 111 LUAD and 31 LUSC cases were consecutively enrolled from April 2019 to October 2020 in Hunan Provincial People’s Hospital. The clinical features of the patients were retrospectively analyzed and compared in the terms of general information, clinicopathologic characteristics, imaging findings and laboratory data.ResultsIn comparison with LUAD, LUSC patients had a significantly higher proportion of males, smokers, drinkers, higher-stage cases. The mean tumor size in LUSC patients was significantly larger than that in LUAD patients. Compared with LUAD patients, more of patients with LUSC had cough, fever and abundant sputum symptoms. Besides that, more bacterial infections and fungal infections were found in LUSC patients than that in LUAD patients. Imaging data shows that ground-glass opacity and patchy shadows in radiological films were more frequent in LUAD patients than that in LUSC patients. In addition to initial laboratory data, LUSC patients had higher levels of leukocytes, platelets, and creatinine that of LUAD patients.ConclusionsTogether, these results suggested that there exist distinct differences between LUAD and LUSC subtypes; LUSC may be a more malignant type in comparison with LUAD. Our findings may have potential implications in clinical settings. However, further multicenter studies are needed to validate these findings in a larger sample size.

Results From Drug-Drug Interaction Studies In Vitro and In Vivo Investigating the Inhibitory Effect of Finerenone on the Drug Transporters BCRP, OATP1B1, and OATP1B3.

Background and ObjectivesIn vitro and in vivo studies were performed with the novel, selective, nonsteroidal mineralocorticoid receptor antagonist finerenone to assess the relevance of inhibitory effects on the transporters breast cancer resistance protein (BCRP), organic anion transporting polypeptide 1B1 (OATP1B1), and OATP1B3. These transporters are involved in the disposition of a number of drugs, including statins. Statins are also a frequent comedication in patients receiving finerenone. Therefore, inhibitory effects on BCRP and OATPs are of potential clinical relevance.MethodsThe effect on the transport of specific substrates of BCRP and OATP1B1/1B3 was assessed in cell-based in vitro assays with finerenone or its metabolites. A fixed-sequence crossover study in 14 healthy male volunteers investigated the effects of finerenone (40 mg once daily) on the pharmacokinetics of the index substrate rosuvastatin (5 mg) administered alone, simultaneously with, or approximately 4 h before finerenone. The effect of finerenone on the endogenous OATP substrates coproporphyrin I and III was also assessed.ResultsBased on in vitro findings and threshold values proposed in regulatory guidelines, finerenone appeared to be a potentially relevant inhibitor of all three transporters. Relevant inhibition could also not be ruled out for the finerenone metabolites M1a (OATP1B1) and M3a (OATP1B1 and OAT1B3), which prompted an investigation into the relevance of these findings in vivo. After administration on a background of finerenone 40 mg, all point estimates of area under the curve ratios (114.47% [rosuvastatin], 99.62% [coproporphyrin I; simultaneous], and 105.28% [rosuvastatin; 4 h separation]) and maximum concentration ratios (111.24% [rosuvastatin], 101.22% [coproporphyrin I], 89.14% [coproporphyrin III; simultaneous], and 96.84% [rosuvastatin; 4 h separation]) of the investigated substrates were within 80.0–125%. In addition, the 90% confidence intervals of the ratios were within the conventional no-effect boundaries of 80.0% and 125% for rosuvastatin after temporally separated administration, and for coproporphyrin I and III.ConclusionAdministration of finerenone 40 mg once daily confers no risk of clinically relevant drug–drug interactions with substrates of BCRP, OATP1B1, or OATP1B3. The potential for relevant inhibition of these transporters suggested by in vitro findings was not confirmed in vivo.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13318-022-00794-5.

AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury.

AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury.

Teaching veterinary surgical skills: Comparison of massed versus spaced instruction.

To determine the effect of massed instruction (MI) versus spaced instruction (SI) of veterinary surgical skills on students' cognitive load and skill retention. Prospective randomized cohort study STUDY POPULATION: First-year veterinary students from Louisiana State University (LSU; n=47) and Lincoln Memorial University (LMU; n=101). Students were randomized to MI (two skills in a single session of twice the duration) or SI (one skill per session on two consecutive days). Instructors, instructional ratio, and total educational time was equivalent. Following instruction, students completed a cognitive load questionnaire and underwent a structured assessment immediately after (LMU only), 1day after, and 3-4 weeks after learning the second skill. Students completed two supervised practice sessions one and 2 weeks after the initial laboratory session(s). Overall cognitive load did not differ between groups (p > .05), although LMUs MI group reported higher physical and time demands, effort, and frustration. At initial assessment, SI students scored higher than MI students for the first skill at both LSU (mean checklist score=27.7 vs. mean=24; p=.004) and LMU (mean global rating score=4.76 vs. mean=4.55; p=.029). Differences between groups were no longer evident by 3-4 weeks after instruction. SI may lead to improved immediate performance; however, supervised practice was sufficient to overcome the initial disparity. SI may be beneficial for initial skill performance. However, SI and MI students had similar performance after 3 weeks, suggesting the more convenient curricular design of MI may be sufficient as long as practice sessions are incorporated.

Chronic kidney disease as cardiovascular risk factor in routine clinical practice: a position statement by the Council of the European Renal Association.

The European Society of Cardiology 2021 guideline on cardiovascular (CV) disease (CVD) prevention in clinical practice has major implications for both CV risk screening and kidney health of interest to primary care physicians, cardiologists, nephrologists, and other professionals involved in CVD prevention. The proposed CVD prevention strategies require as first step the categorization of individuals into those with established atherosclerotic CVD, diabetes, familiar hypercholesterolaemia, or chronic kidney disease (CKD), i.e. conditions that are already associated with a moderate to very-high CVD risk. This places CKD, defined as decreased kidney function or increased albuminuria as a starting step for CVD risk assessment. Thus, for adequate CVD risk assessment, patients with diabetes, familiar hypercholesterolaemia, or CKD should be identified by an initial laboratory assessment that requires not only serum to assess glucose, cholesterol, and creatinine to estimate the glomerular filtration rate, but also urine to assess albuminuria. The addition of albuminuria as an entry-level step in CVD risk assessment should change clinical practice as it differs from the current healthcare situation in which albuminuria is only assessed in persons already considered to be at high risk of CVD. A diagnosis of moderate of severe CKD requires a specific set of interventions to prevent CVD. Further research should address the optimal method for CV risk assessment that includes CKD assessment in the general population, i.e. whether this should remain opportunistic screening or whether systematic screening.