Point-of-care ultrasonography as a training milestone for internal medicine residents: the time is now

Point-of-care (POC) ultrasonography is considered fundamental in emergency medicine training and recently has become a milestone in critical care fellowship programs as well. Currently, there is no such standard requirement for internal medicine residency programs in the United States. We present a new case and briefly review another case at our institution – a community hospital – in which internal medicine house staff trained in ultrasonography were able to uncover unexpected and critical diagnoses that significantly changed patient care and outcomes. We also review the growing evidence of the application of ultrasound in the diagnosis of a myriad of conditions encountered in general internal medicine as well as the mounting data on the ability of internal medicine residents to apply this technology accurately at the bedside. We advocate that the literature has sufficiently established the role of POC ultrasonography in general internal medicine that there should no longer be any delay in giving this an official place in the development of internal medicine trainees. This may be particularly useful in the community hospital setting where 24-h echocardiography or other sonography may not be readily available

Control of bleeding from intercostal artery laceration

Laceration of an intercostal artery is a rare but potentially catastrophic complication of pleural procedures such as thoracentesis. Recognition of this problem often occurs late in the bleeding process, only after hemodynamic decompensation has occurred. Aggressive and emergent measures are usually undertaken such as angiographic embolization or thoracotomy. In our review of the literature, manual pressure over the pleural space is not described as an intervention in case reports or case series. We demonstrate the first video proof of the immediate success of direct pressure over an intercostal site as a simple, rapid, and effective method for definitively stopping intercostal arterial hemorrhage after a pleural procedure

Interactions between c-Jun, Nuclear Factor 1, and JC Virus Promoter Sequences: Implications for Viral Tropism

The infectious cycle of the human polyomavirus JC (JCV) is ultimately regulated in cellular nuclei at the level of viral protein expression and genomic replication. Such activity is prompted by interactions between variant nucleotide sequences within the JCV regulatory region (promoter) and cellular transcription factors that bind specific DNA consensus sites. In previous work we identified an NF-1 class member, NF-1X, as a critical transcription factor affecting the JCV cellular host range. Within variant JCV promoters, as well as other viral and cellular promoters, adjacently located NF-1 and AP-1 consensus sites are often found. The close proximity of these two binding sites suggests the opportunity for interaction between NF-1 and AP-1 proteins. Here, by electrophoretic mobility shift assays, we show temporal and dose-dependent interference by an AP-1 family member, c-Jun, upon NF-1 proteins binding an NF-1 consensus site derived from JCV promoter sequence. Moreover, as demonstrated by protein-protein interaction assays, we identify specific binding affinity independent of DNA binding between NF-1X and c-Jun. Finally, to compare the binding profiles of NF-1X and c-Jun on JCV promoter sequence in parallel with in vivo detection of viral activity levels, we developed an anchored transcriptional promoter (ATP) assay. With use of extracts from JCV-infected cells transfected to overexpress either NF-1X or c-Jun, ATP assays showed concurrent increases in NF-1X binding and viral protein expression. Conversely, increased c-Jun binding accompanied decreases in both NF-1X binding and viral protein expression. Therefore, inhibition of NF-1X binding by c-Jun appears to play a role in regulating levels of JCV activity