A Case of COVID-19 Pneumonia Leading to Acute Respiratory Distress Syndrome (ARDS) and Multi-organ Failure Requiring Extracorporeal Membrane Oxygenation (ECMO) for Six Months and an Associated Critical Limb Ischemia.

This article presents the case of a 57-year-old woman with a history of rheumatoid arthritis who developed severe coronavirus disease 2019 (COVID-19) pneumonia that progressed to acute respiratory distress syndrome (ARDS) and multi-system organ failure. Despite initial slow progression and multiple hospital readmissions, her condition rapidly deteriorated, leading to full respiratory failure requiring intubation and ventilation. She was transferred to a specialized center where she underwent extracorporeal membrane oxygenation (ECMO) and hemodialysis for acute renal failure. Unfortunately, she remained dependent on ECMO for an extended period of six months. Although she made a gradual recovery, the prolonged critical care treatment resulted in critical ischemia of multiple extremities, necessitating a below-knee amputation (BKA) of her left lower extremity and transmetatarsal amputations of her right hand. This case reports one of the longest ECMO treatments for COVID-19 and associated comorbidities in the literature. Clinicians could include a longer duration of treatment and potential associated disabilities in the informed consent.

Knowledge and Behavior of Primary Care Physicians Regarding Utilization of Standardized Tools in Screening and Assessment of Anxiety, Depression, and Mood Disorders at a Large Integrated Health System.

INTRODUCTION: Standardized screening, objective evaluation, and management of behavioral health conditions are major challenges in primary care. The Generalized Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire (PHQ-9), and Mood Disorder Questionnaire (MDQ) provide standardized screening and symptom management tools for generalized anxiety disorder (GAD), major depressive disorder (MDD), and Mood Disorders (MD), respectively. This study explores family physicians' knowledge, attitudes, and practices regarding the utilization of GAD-7, PHQ-9, and MDQ in outpatient primary care offices. METHODS: The study method was a cross-sectional electronic and paper survey utilizing a self-administered questionnaire that assessed primary care physicians' demographics, knowledge, attitudes, and practices in rural and urban outpatient clinical settings regarding GAD-7, PHQ-9, and MDQ. Statistical software SAS 9.4 was used for descriptive and Chi-Square statistics. RESULTS: Out of 320 total participants,145 responded (45.3%). Responding family physicians demonstrated a high level of familiarity with the GAD-7 (97.9%), PHQ-9 (97.9%), and MDQ (81.3%) assessment tools. However, the reported utilization rates were relatively lower than knowledge, with 62.7%, 73.1%, and 31.9% extremely likely or likely to utilize the GAD-7, PHQ-9, and MDQ as screening and monitoring tools, respectively. Less than a quarter of the total respondents use the objective score for the future management of GAD, with significantly more residents utilizing the score for GAD-7 compared to attendings (P < .05). There was no statistical significance difference between residents and attendings for the objective evaluation of Major Depressive Disorder (P = .26) and Mood Disorders (P = .05). CONCLUSIONS: Despite being knowledgeable of the utility of GAD-7, PHQ-9, and MDQ, the primary care physicians in a large integrated health system in Central Pennsylvania and Northern Maryland report inconsistent utilization in their practice. Further studies are needed to determine the underlying factors contributing to the suboptimal usage of these screening tools and ways to increase it.

Acute Gastrointestinal Bleeding: A Report of Rare Presentation of Duodenal Metastasis From Cervical Squamous Cell Carcinoma.

We report a case of a 42-year-old gravida 3, para 4 woman from Puerto Rico with a history of cervical cancer who presented with dizziness, lethargy, and three days of bright red blood per rectum. Imaging evaluation showed a retroperitoneal lymph node mass with secondary metastasis to the duodenum. After she was stabilized with multiple blood transfusions and to mitigate her ongoing bleeding, she was transferred to a tertiary care hospital for possible embolization by interventional radiologists. However, she was deemed a poor candidate for an interventional procedure and decided to ultimately go home on hospice care. This case highlights the rarity of duodenal metastasis presenting as gastrointestinal bleeding due to cervical squamous cell cancer and further reinforces the need for human papillomavirus vaccination and cervical cancer screening. This case study also illustrates that even though cervical cancer rates are low in the United States, it is still deadly in many countries across the globe. As people continue to travel and migrate across borders, the risk of being lost to follow-up is on the rise.

Applicants' Interview Experience of Family Medicine Residency Match: Reflections from a Quality Improvement Initiative at a Community Hospital.

Background and objective Both family medicine applicants and programs dedicate significant resources to the interview process, a time for both parties to make an impression on the other in an attempt to find their best match. Despite the importance of this process, little research has been completed to ensure the process efficiently addresses applicant preferences on interview day and the surrounding process. This study aimed to determine the factors influencing the family medicine applicant preferences regarding the pre-interview, interview, and post-interview ranking process.  Methods The study method was a cross-sectional electronic survey utilizing anonymous questionnaires that assessed demographics, pre-interview, interview, post-interview ranking preference, and applicants' experiences applying to a community-based family medicine residency program after their interview for the 2020 application cycle. Results Out of the 106 family medicine applicants, 48 responded; 52.08% were males, 52.5% were married, 58.33% applicants were from the osteopathic medical school, 33.33% were from the allopathic Liaison Committee on Medical Education (LCME) non accredited medical school/international medical graduates (IMG's), and 8.33% were from the allopathic LCME accredited medical schools. Free hotel accommodation was not offered from half of the programs to 27.8% of the applicants in the 2020 match cycle (pre-pandemic). Respondents favored electronic means of scheduling interviews with a positive experience with the online self-scheduling Electronic Residency Application Service (ERAS) calendar. A significantly higher proportion of IMGs applied to a higher number of family medicine programs followed by the osteopathic applicants. There was no statistical difference found between osteopathic and allopathic applicants for the number of programs they got invited to; however, the difference was significant for osteopathic and allopathic LCME accredited applicants who interviewed and ranked programs in the range of 11-20 (62.96%, p=0.0013 and 66.67%, p=0.0018, respectively). The respondents' most important experiences were interviewing the program director, faculty members, and tour the hospital facility. When ranking programs, these family medicine applicants considered the strength of program training, the quality of current residents, and the program's geographic location as the top three most significant factors, with mean importance ratings of 5.08, 5.02, and 4.35, respectively. Applicants also considered how the current residents perceive the program director, prior teaching experience, and program diversity with mean importance ratings of 3.42, 2.89, and 2.09, respectively. Conclusion Although applicants' preferences for family medicine residency programs are similar to generally reported by The National Resident Matching Program (NRMP) surveys, some key differences do exist. The program leadership should consider these preferences from the candidates' perspective for a successful match in family medicine residency on both sides.

Ruptured Right Broad Ligament Ectopic Pregnancy in a Patient With Prior Right Salpingo-Oophorectomy: A Case Report.

Ectopic pregnancy can be a life-threatening cause of acute abdomen. Broad ligament pregnancy accounts for 1% of ectopic abdominal pregnancies and complications can be calamitous. This case report highlights a 27-year-old G2P0010 female who presented with amenorrhea and acute right lower quadrant and pelvic pain. By last menstrual period (LMP), she was at seven weeks and two days gestation. Her past surgical history was significant for a prior right salpingo-oophorectomy. The physical examination was significant for severe right lower quadrant tenderness with guarding. The urine pregnancy test was positive with the serum quantitative beta-human chorionic gonadotrophin (Beta hCG) of 28011 MIU/ML (normal range <5 MIU/ML). The transvaginal ultrasonography demonstrated an empty uterus and a gestational sac containing a fetal pole in the right adnexal area. The crown-rump length was 7.2 mm, consistent with six weeks and four days, with a positive fetal heart rate and moderate free fluid in the cul-de-sac. The patient was taken for immediate diagnostic laparoscopy, which was converted to open laparotomy due to active bleeding from the right broad ligament and pelvic wall close to large pelvic vessels. In addition to the hemoperitoneum, intraoperative findings revealed a normal left fallopian tube and ovary and absent right fallopian tube and ovary. Right ureterolysis was done and hemostasis of the bleeding broad ligament and right pelvic sidewall was established. An adherent tissue was dissected from the right broad ligament and sent to pathology. The patient did well postoperatively. The final pathology showed an ectopic pregnancy with immature chorionic villi in the broad ligament. The diagnosis of ectopic pregnancy in the broad ligament is challenging. The location could be close to the major pelvic vessels and anatomic structures like the ureter and bowel, hence, it can cause massive hemorrhage with maternal morbidity and mortality. Diagnosis is often missed preoperatively and made intraoperatively. Hence, we emphasize that this differential be considered in reproductive-aged women who present with atypical presentations of acute abdomen and amenorrhea.

Left Ovarian Vein Thrombosis Presenting as Acute Postpartum Pyelonephritis.

Ovarian Vein Thrombosis (OVT) is an extremely rare and uncommon thrombotic condition commonly attributed to the postpartum period. We report a case of a 30 yr old P2002 who presented with one day history of fever, chills, vomiting, abdominal and left flank pain. Patient had a preterm vaginal birth at 34 weeks gestation, four days prior to her presentation. Patient was febrile on presentation with left CVA tenderness and diffuse abdominal tenderness. Pelvic Ultrasound showed enlarged uterus 14.7cm x 10.9cm x 8.5cm consistent with a postpartum uterus, with heterogeneous endometrium 2.3 cm, no retained products and normal adnexa. CT scan with contrast showed fluid along the anterior aspect of the left anterior kidney, left psoas muscle and extending down to the left side of the uterus and extending to the region of the left renal vein which confirmed left ovarian thrombosis. A CT Chest with contrast and bilateral lower extremity Doppler ruled out pulmonary embolism and deep vein thrombosis, respectively.The patient was admitted, treated with antibiotics and therapeutic dose of low molecular weight heparin (Enoxaparin) and responded well. Patient was discharged home on oral apixaban. The clinical presentation of OVT is non-specific and can be similar to that of acute pyelonephritis. Physicians should have a high index of suspicion in postpartum patients presenting with flank pain and imaging techniques such as MRI, CT scan and ultrasound should be used to help in making the diagnosis.

Development of a Culture of Scholarship: The Impact of a Structured Roadmap for Scholarly Activity in Family Medicine Residency Program.

INTRODUCTION: The Accreditation Council of Graduate Medical Education (ACGME) mandates resident scholarship in all residency programs. Resident scholarship requirement continues to be one of the most common citations by the Residency Review Committee (RRC). This study evaluates the impact of a structured roadmap for resident scholarly activity in a single-family medicine residency program. METHODS: This retrospective study compares resident scholarship before and after exposure to a structured roadmap for scholarly activity as well as characteristics associated with higher scholarship productivity. The data was analyzed using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL) version 16.0. Student's t-test was used to calculate the statistically significant difference. RESULTS: There were a total of 16 residents who graduated in the first cohort whereas the second cohort consisted of 18 residents. There was a steady increase in resident scholarly activity over time. The number of publications by those who were exposed to a 13-step structured roadmap for scholarly activity was more than twice when compared with the first cohort. Those who pursued a fellowship after residency published three times more than those who did not. CONCLUSION: Exposure to a structured roadmap for scholarly activity may be associated with higher production of resident scholarly activity. Larger studies comparing national level data from isolated community hospitals and big academic centers are needed for a conclusive argument. Although the availability of resources may increase the likelihood of more scholarship, the establishment of a research culture is more important. Further studies are needed to determine the factors which lead to the establishment of research culture in a residency program.

Extrapelvic endometrioma presenting as acute incarcerated right inguinal hernia in a postpartum patient.

A 33-year-old postpartum patient, who had an uncomplicated repeat caesarean section 4 weeks prior, presented with a 2-day history of acute right lower quadrant, incisional and groin pain. She was found to have a palpable tender lump in the right groin. A CT scan with contrast identified fluid along the anterior abdominal wall of the right lower quadrant (inguinal region) measuring about 1.7 cm, a preliminary diagnosis of an incarcerated inguinal hernia was made and the patient underwent immediate surgery. The hernia sac was dissected free and had chocolate cyst that was confirmed to be endometrioma on histopathology. The hernia defect was repaired. Postoperative, the patient did well and was discharged home. We emphasise to consider this differential diagnosis of extrapelvic inguinal endometrioma in reproductive-aged women with or without history of endometriosis especially in a post-caesarean patient who has atypical presentations.

A Rare Case of Sclerosing Stromal Tumor of the Ovary Presenting in Pregnancy: A Diagnostic Dilemma on Presentation.

Sclerosing stromal tumor (SST) is a rare benign neoplasm of the ovary. There are only a few cases of sclerosing stromal tumor of the ovary during pregnancy that have been reported in the literature. The presenting symptoms are nonspecific, including pelvic pain or menstrual irregularities. We describe a case of a young 22-year-old pregnant woman who presented with pelvic pain in the second trimester. On imaging she was found to have a 12 cm left adnexal mass with solid features on MRI. The patient underwent exploratory laparotomy and removal of the mass that was attached to the left ovary via a stalk with preservation of the left ovary. The frozen section diagnosis was "sex cord stromal tumor, favor benign". The final pathology confirmed the diagnosis of the sclerosing stromal tumor of the ovary where characteristic features of SST including a heterogenous, pseudolobular growth pattern with hypercellular and hypocellular areas were identified along with prominent luteinized stromal cells attributed to pregnancy. In this case report and review of literature, we emphasize consideration of this rare ovarian tumor in the differential diagnosis for a young pregnant woman who presents with pelvic pain.

Knowledge of ovarian reserve and reproductive choices.

OBJECTIVE: To determine the factors that influence the reproductive choices of health care professionals, and to assess whether knowledge of ovarian reserve would modify those choices. METHOD: A cross-sectional survey utilizing anonymous questionnaires that assessed demographics, knowledge, attitudes and choices of female and male health care professionals between the ages of 20-55 (N = 185) who work at an academic medical center RESULT(S): Of the 185 respondents, 75% were female, 35% were residents and 35% were married. Among those who were delaying childbearing 39% wanted to complete their education, 25% had no identified partner, 10% were too active professionally and 4% could not afford children at the time. If testing of the individual or individual's partner indicated diminished ovarian reserve, 48% of those responding would try to have a child sooner, 21% would opt for oocyte cryopreservation, 7% would try to find a partner sooner, 7% would pursue adoption, and 3% would select embryo cryopreservation. Only 14% would not actively pursue treatment or make lifestyle changes. These results varied significantly with marital status but did not differ between participants with and without children. Similarly, choices did not vary significantly with religious belief or ethnicity. CONCLUSION(S): Increased information about a woman's reproductive reserve would lead individuals to modify life choices. Physicians caring for reproductive-age women and men should inquire about their childbearing plans, and educate those who are postponing childbearing regarding the normal pattern of reproductive decline.

Predictors of H1N1 vaccination in pregnancy.

The purpose of this review was to determine factors that influence a pregnant woman's acceptance of the H1N1 vaccine with the use of the Health Belief Model (HBM). A self-administered questionnaire based on the HBM was used in a cross-sectional study of postpartum women during the 2009 H1N1 epidemic. Overall, 212 postpartum women were approached and agreed to participate; of these women, 25.5% had received an H1N1 vaccination. Perceived barriers to vaccination (P = .001) and perceived severity of infection (P = .018) were independent predictors of vaccination. The total predictive utility of the full model that incorporated HBM dimensions, age, race, care provider, and education level was moderate (area under the curve, -0.86). The addressing of perceived barriers (such as fear of side-effects), an explanation of the safety of the vaccine for the fetus, and the stressing of complications that are associated with H1N1 infection in pregnancy may increase the rate of vaccination.