Retroperitoneal Tumor, a Primary Cavernous Hemangioma: A Case Report.

The diagnosis of primary retroperitoneal cavernous hemangiomas is extremely rare in clinical practice. Only a few cases have been reported. Due to the lack of specific radiological features, their diagnosis is uncommon. They are usually found incidentally or after symptoms as a consequence of complications. Adult retroperitoneal cavernous hemangiomas are extremely rare. This is a report of a rare case of a primary retroperitoneal cavernous hemangioma in a 45-year-old male patient discovered after acute appendicitis. A histopathological examination is conducted following total surgical resection to confirm the diagnosis.

Point-of-Care Ultrasonography in Internal Medicine: Limitations and Pitfalls for Novice Users.

Point-of-care ultrasound (POCUS) is increasingly being adopted in the field of internal medicine, leading to the development of POCUS curricula in undergraduate and postgraduate medical education programs. Prominent internal medicine societies and organizations worldwide recognize the expanding utilization of POCUS by internal medicine physicians, emphasizing the need for practitioners to be aware of both its benefits and limitations. Despite the growing enthusiasm for POCUS, clinicians, particularly those with limited clinical experience, must be cautious regarding its inherent limitations and the potential impact on their clinical practice. This review aims to outline the limitations and potential drawbacks of POCUS for medical students, residents, and internists who wish to stay abreast of the escalating use of POCUS in internal medicine and have a desire, or have already commenced, to incorporate POCUS into their practice. Additionally, it provides recommendations for enhancing POCUS proficiency to mitigate these limitations.

Lipoleiomyoma With Bizarre Nuclei and Abundant Mast Cells.

Lipoleiomyoma is an uncommon neoplasm of the uterus with a variable incidence in the literature. Histologically, it consists of smooth muscle cells intermixed with mature adipocytes. The histogenesis of this tumor remains obscure and the presence of atypical cells may raise the suspicion of leiomyosarcoma so it is crucial to distinguish between the two. On the other hand, tumor-associated mast cells are being recognized as tumor modulators and potential therapeutic targets. Here, we discuss the case of a 57-year-old female, who presented with a nonspecific symptom of postmenopausal bleeding. She was found to have a large uterine mass and had been treated surgically with a hysterectomy. Histological examination revealed the diagnosis of this uncommon entity. Considering the rarity of the disease, we report this case to add to the existing literature. Furthermore, the significance of these findings is still poorly understood and needs more investigation to fill in the lacking knowledge.

Diagnosing Pulmonary Embolism Using Point-of-Care Ultrasound in a Patient With Malingering and Coccidioidomycosis Infection.

We report a case of a 41-year-old male diagnosed with pulmonary coccidioidomycosis and pulmonary embolism (PE) based on a point-of-care ultrasound (POCUS) finding who was suspected to be malingering for right-sided chest pain considering his psychiatric history. POCUS was performed and showed right ventricular strain with a D-shaped left ventricle and B-lines with subpleural consolidations, and PE was confirmed with computed tomography pulmonary angiography. No other risk factors for PE were found except for coccidioidomycosis. The patient was treated with apixaban and fluconazole and discharged in stable condition. We discuss the usefulness of POCUS in diagnosing PE and the very rare association between coccidioidomycosis and PE.

Hydroxyurea-Induced Acute Pancreatitis.

Drug-induced pancreatitis (DIP), while not a major cause of acute pancreatitis, remains a debilitating diagnosis resulting in significant patient morbidity and mortality. The diagnosis includes first diagnosing acute pancreatitis, second ruling out more common etiologies (alcohol abuse, gallstones, etc.), and third documenting a thorough history (in particular medications). Essentially, it is a diagnosis of exclusion. Any drugs with the potential to result in acute pancreatitis should be discontinued, and those without future recurrence of pancreatitis are deemed to have had a drug-induced case. Although the exact pathophysiology of the initial development of DIP is unknown, we hypothesize it is different for various drug classes. It is known that once pancreatic enzymes are activated after insult, they activate an inflammatory response resulting in auto-digestion of the pancreas. Our report discusses a previously not documented case of DIP in a patient on hydroxyurea monotherapy for the treatment of Janus kinase 2 (JAK2) essential thrombocytosis.

Point-of-Care Ultrasound Curriculum for Internal Medicine Residents During the COVID-19 Era: A Pilot Study.

INTRODUCTION: The use of point-of-care ultrasound (POCUS) by internal medicine physicians and residents is increasing. We present the results of a pilot study to implement a POCUS curriculum that was interrupted by the Coronavirus Disease 2019 (COVID-19) pandemic at an internal medicine residency program at a community hospital. The purpose of this study is to inquire about the attitude and interest of our medical residents in POCUS. Additionally, we also plan to examine whether a curriculum that lacks some practical aspects due to COVID-19 restrictions can still improve the residents' confidence in recognizing common POCUS applications and improve image interpretation skills. METHODS: We conducted a prospective, pre-, and post-curriculum pilot study to examine the POCUS skills of categorical internal medicine residents in Post-Graduate Years (PGY) 1 through 3 at a community hospital. The two POCUS-related skills examined were self-reported confidence level in recognizing certain POCUS examination findings and POCUS image interpretation skills. Due to social distancing guidelines, we were unable to host hands-on sessions as originally planned, but residents did receive lectures via Zoom regarding POCUS training and also organ-specific diagnoses. Three primary outcomes were measured: (1) baseline difference in confidence level between interns (PGY-1) and senior residents (PGY-2 and 3) at the beginning of the curriculum, (2) improvement in POCUS confidence level before and after the curriculum considering interns and senior residents all together and also separately, and (3) improvement in image interpretation skills before and after the curriculum. RESULTS: Of 41 residents, 23 participants completed the pre- and post-curriculum test. Of the 23 participants, 12 participants were interns, and 11 were senior residents. Overall, interns showed a statistically significant improvement in the confidence level in almost all diagnoses except pulmonary embolism (p = 0.084). For image interpretation tests, significant improvement was found only in recognizing the two signs of pneumothorax: pleural line absent sliding (X2 = 4.00, p < 0.05) and the barcode sign (X2 = 6.13, p < 0.05). The pre-curriculum confidence level questionnaire included a question about residents' interest in learning POCUS during residency. It showed that the vast majority of residents (21 residents [91%]) are either extremely or mostly interested in POCUS. Most of our residents (18 [78%]) did not have formal exposure to POCUS during medical school. CONCLUSION: A POCUS curriculum that lacks hands-on workshops and longitudinal image saving and reviewing due to the COVID-19 pandemic restrictions did not improve the residents' image interpretation skills, although the confidence levels of the interns statistically improved. After the pandemic, we plan to implement the full curriculum and examine whether it will improve the residents' image acquisition and interpretation skills.

Rings Flying Around: A rare complication of Transjugular Intrahepatic Portosystemic Shunt.

We present a rare case of TIPS stent migration. TIPS is considered a relatively safe procedure with a high success rate. We present a case of 58 year old male with decompensated alcoholic liver cirrhosis requiring TIPS stent, which fractured and migrated into the pulmonary artery. Our case represents a rare complication, reported only 4% of the population. RINGS FLYING AROUND: a rare complication of Transjugular Intrahepatic Portosystemic Shunt.

Real-Time Human Recognition at Night via Integrated Face and Gait Recognition Technologies.

Human recognition technology is a task that determines the people existing in images with the purpose of identifying them. However, automatic human recognition at night is still a challenge because of its need to align requirements with a high accuracy rate and speed. This article aims to design a novel approach that applies integrated face and gait analyses to enhance the performance of real-time human recognition in TIR images at night under various walking conditions. Therefore, a new network is proposed to improve the YOLOv3 model by fusing face and gait classifiers to identify individuals automatically. This network optimizes the TIR images, provides more accurate features (face, gait, and body segment) of the person, and possesses it through the PDM-Net to detect the person class; then, PRM-Net classifies the images for human recognition. The proposed methodology uses accurate features to form the face and gait signatures by applying the YOLO-face algorithm and YOLO algorithm. This approach was pre-trained on three night (DHU Night, FLIR, and KAIST) databases to simulate realistic conditions during the surveillance-protecting areas. The experimental results determined that the proposed method is superior to other results-related methods in the same night databases in accuracy and detection time.

The Conundrum of Volume Status Assessment: Revisiting Current and Future Tools Available for Physicians at the Bedside.

Assessment of patients' volume status at the bedside is a very important clinical skill that physicians need in many clinical scenarios. Hypovolemia with hypotension and tissue under-perfusion are usually more alarming to physicians, but hypervolemia is also associated with poor outcomes, making euvolemia a crucial goal in clinical practice. Nevertheless, the assessment of volume status can be challenging, especially in the absence of a gold standard test that is reliable and easily accessible to assist with clinical decision-making. Physicians need to have a broad knowledge of the individual non-invasive clinical tools available for them at the bedside to evaluate volume status. In this review, we will discuss the strengths and limitations of the traditional tools, which include careful history taking, physical examination, and basic laboratory tests, and also include the relatively new tool of point-of-care ultrasound.

Small bowel obstruction secondary to primary enterolith: A rare and delayed complication of radiation enteritis.

Primary enteroliths as a result of pelvic radiotherapy are a rare cause of intestinal obstruction.

Feel It, See It, Get It: Is Internal Medicine Residents' Use of Ultrasound in Lumbar Puncture Associated With Higher Success Rate?

INTRODUCTION:  Multiple emergency medicine and anesthesiology research studies suggest that ultrasound (US) is potentially useful in assisting with needle insertion in a lumbar puncture (LP). However, little is known about its value when utilized by internal medicine (IM) residents. The objective of this study is to examine whether the use of ultrasound in LPs performed by internal medicine residents is associated with a higher success rate than the traditional palpation method. MATERIALS AND METHODS:  We reviewed all LP procedure notes in our hospital's records written by IM residents from June 2017 to December 2018 in a single community teaching hospital. We examined the association between the US use and success using the Chi-squared test and logistic regression model. RESULTS: Among the 152 lumbar punctures documented, 130 specified whether US was used or not. Among these, 39 were ultrasound-assisted and 91 were not. Use of ultrasound was associated with a higher success rate compared to the non-ultrasound-use (87% vs 73%; p=0.1). The association was strengthened using logistic regression but did not reach statistical significance (OR 3.5; CI: 0.9 -13.8; p=0.07). Success was significantly associated with a fewer number of attempts (p<0.001). No statistically significant association was found between success and patients' body mass index (BMI; p=0.57), or level of training (p=0.11). CONCLUSIONS:  Use of ultrasound for needle insertion in lumbar punctures performed by internal medicine residents was associated with a higher success rate compared to the palpation method but without statistical significance. Ultrasound is a non-invasive, quick, and safe tool. Our study favors its use as an aid during lumbar puncture when performed by internal medicine residents. Larger studies are needed to gather more evidence in support of this conclusion.

Internal medicine residents' point-of-care ultrasound skills and need assessment and the role of medical school training.

Introduction: Point-of-care-ultrasound (POCUS) as a useful bedside tool is growing. Few studies have examined residents' attitude towards POCUS or compared POCUS image interpretation skills between residents with and without POCUS training in medical school. Material and Methods: We distributed an anonymous survey and image interpretation test to assess residents' attitude towards POCUS, confidence, and skills in interpreting POCUS images and videos. Using independent samples t-tests, we compared mean confidence levels and test scores between residents with and without prior POCUS training. Results: Fifty-two residents responded to survey (response rate 68%) and 59 took the image interpretation test (77%). Most residents (90%) reported being interested in POCUS. Residents with prior POCUS training (n=13) were either PGY-1 (9) or PGY-2 (4). No PGY-3 resident had prior training. Most residents (83%) thought POCUS could be extremely useful in the inpatient setting compared to 29% for outpatient setting. PGY-1 residents with prior training had a higher mean confidence level than PGY-1 residents without prior training, but the difference was not statistically significant (3.26 vs 2.64; p=0.08). PGY-1 with prior training had a mean confidence level that was close to that of PGY-3 residents. PGY-1 residents with prior training scored significantly higher than PGY-1 residents without prior training in image interpretation test (10.25 vs 7; p=0.01). Residents felt most confident in interpreting inferior vena cava images (mean 3.7; max. 5), which also had the highest score in image interpretation test (correct response rate of 88%). Conclusion: Our residents seem very interested in POCUS. PGY-1 residents with prior POCUS training in medical school seem to have higher confidence in their POCUS skills than PGY-1 residents without prior training and outperformed them in image interpretation test. The study is very instructive in building our future POCUS curriculum for residents.

Quality Aspects of Insects as Food-Nutritional, Sensory, and Related Concepts.

In the search for another appealing source of future food to cover the increasing need for nutrients of a growing global population, this study reviewed the potential of insects as human food. Most previous reviews have dealt with insects as a group, making it difficult to evaluate each individual insect species as food because of the generalized data. This study assessed some common edible insects, but concentrated on mealworms. Insects, especially mealworms, have a similar or higher nutritional value than many conventional food sources. For example, the protein content of mealworm larvae is reported to be almost 50% of dry weight, while the fat content is about 30% of larval dry weight. Mealworms can be cooked by different methods, such as hot air drying, oven broiling, roasting, pan frying, deep frying, boiling, steaming, and microwaving. Oven broiling in particular gives a desirable aroma of steamed corn for consumers. Changes in the flavor, taste, and texture of mealworm products during storage have not been studied, but must be determined before mealworms can be used as a commercial food source. Factors controlling the shelf-life of mealworms, such as their packaging and storage, should be identified and considered with respect to the feasibility of using mealworms on a commercial scale.

Spontaneous renal artery dissection associated with sexual intercourse: a case report.

Spontaneous renal artery dissection is a rare cause of renal infarction and can be a diagnostic challenge at times, necessitating high index of suspicion. Other common underlying causes, especially thromboembolic phenomena, need to be considered and investigated first before making this uncommon diagnosis with vascular imaging studies. Very few cases did report strenuous exercise as a predisposing factor for the development of spontaneous renal artery dissection, but we believe that sexual intercourse has not been reported before as an underlying precipitating etiology. We report a case of a young male who presented with renal infarction that started during sexual intercourse and was found to have an angiographically proven renal artery dissection.

In with acute bronchitis; out with duodenal perforation: the potentially harmful cascade of over-testing. A case report.

Overutilization of diagnostic imaging can lead to unnecessary interventions and subsequently can jeopardize patient safety. When ordered, the results of these images should always be interpreted in the appropriate clinical context taking into consideration the patient clinical presentation and the natural history of the diseases which are being investigated. We presented a case that demonstrates for the practicing physicians how violating these two notions can lead ultimately to patient harm.

Formation and properties of viscoelastic masses made from kafirin by a process of simple coacervation from solution in glacial acetic acid using water.

Stable viscoelastic masses have been formed from kafirin in a mainly aqueous system. Kafirin was dissolved in glacial acetic acid (GAA) and simple coacervation was performed by rapid addition of 15°C water under low shear. Kafirin precipitated out as a network of hydrated fibrils which could be hand-kneaded into a viscoelastic mass. These could be formed from a very wide range of kafirins, including those where ß- or γ-subclass expression was suppressed. Kafirin composition influenced the appearance of the masses but did not fundamentally affect stress-relaxation behaviour. Fresh kafirin masses exhibited similar elasticity and viscous flow balance to gluten. They maintained functionality when stored for several days at 10°C but their elastic component increased. FTIR showed that when kafirin was dissolved in GAA its α-helical conformation increased substantially. Dissociation of the kafirin molecules in GAA, assuming a α-helical conformation may have enhanced water binding, enabling viscoelastic mass formation.

The Hospitalist Huddle: a 1-year experience of teaching Hospital Medicine utilizing the concept of peer teaching in medical education.

BACKGROUND: The relatively new specialty of Hospital Medicine in the USA is one of the fastest growing fields in internal medicine. Academic hospitalists are largely involved in the medical education of postgraduate residents and medical students. Little is known about the effectiveness of peer-to-peer teaching in internal medicine residency training programs and how the medical residents perceive its educational value in learning Hospital Medicine. MATERIALS AND METHODS: The Hospitalist Huddle is a weekly educational activity newly established by our Hospitalist Division to facilitate the concept of peer-to-peer teaching. It requires medical residents to teach and educate their peers about the clinical topics related to Hospital Medicine. Faculty hospitalists serve as facilitators during the teaching sessions. A survey disseminated at the end of the first year of its implementation examined the residents' perception of the educational value of this new teaching activity. RESULTS: Most residents reported that they see the Huddle as a useful educational forum which may improve their skills in teaching, create a better educational and learning environment during their inpatient rotation, and improve their understanding of Hospital Medicine. Most residents also prefer that their peers, rather than faculty hospitalists, run the activity and do the teaching. CONCLUSION: The survey results support the notion that teaching and learning with flat hierarchies can be an appealing educational method to medical residents to help them understand Hospital Medicine during their medical wards rotation. Some areas need to be improved and others need to be continued and emphasized in order to make this novel educational activity grow and flourish in terms of its educational value and residents' satisfaction.

Placental malaria and its effect on pregnancy outcomes in Sudanese women from Blue Nile State.

BACKGROUND: Malaria infection during pregnancy can result in placental malaria and is associated with adverse pregnancy outcomes particularly among primigravidae. The aim of this study was to assess the prevalence and risk factors for placental malaria and its effect on pregnancy outcomes in Blue Nile state, Sudan. METHODS: A cross-sectional hospital-based study was conducted consecutively during January 2012-December 2015 in three main hospitals in Blue Nile State, Sudan. At delivery, peripheral and placental blood samples were collected from consenting women. Finger prick blood was used for preparation of peripheral smears and for haemoglobin measurement. Smears were stained with Giemsa and examined microscopically for malaria parasites. Pregnancy outcomes in association to placental malaria were investigated. RESULTS: A total of 1149 mothers and their newborns were recruited. The mean (SD) of the age was 23.3 (5.2) years. Detection of malaria parasites was confirmed in 37.8% of the peripheral blood films and 59.3% of the placental films with Plasmodium falciparum as the only species detected. In multivariate analysis, younger age ≤23.2 years old (AOR = 3.2, 95% CI 1.9-5.5; P < 0.001), primiparae (AOR = 3.9, CI 2.1-7.6; P < 0.001), secundiparae (AOR = 2.8, 95% CI 1.5-5.1; P < 0.001, no antenatal care (ANC) visits (AOR = 11.9, 95% CI 7.8-18.1; P < 0.001) and not using bed nets (AOR = 3.5, 95% CI 1.7-6.8; P < 0.001) were risk factors for placental malaria. Education and residence were not associated with placental malaria infection. Placental malaria was significantly associated with maternal anaemia (AOR = 41.6, 95% CI 23.3-74.4; P < 0.001) and low birth weight (LBW) (AOR = 25.2, 95% CI 15.1-41.3; P < 0.001). CONCLUSION: During the study, there was a high prevalence of placental malaria in Blue Nile State-Sudan, as the enhanced control activities were not practiced, leading to adverse pregnancy outcomes, such as maternal anaemia and LBW.