A Growing Mandate in American Medicine: Teaching Our Internal Medicine Residents About Healthcare Administration and Leadership.

Leadership training during residency is essential for the successful development of contemporary physicians. Creating a curriculum for healthcare leadership and administration for internal medicine residents is particularly challenging due to the heterogeneity of leadership curricula across programs, the emphasis on individual advancement rather than collective leadership, and the scarcity of published research on the topic. A healthcare administration and leadership rotation for medical residents is a valuable experience that emphasizes the importance of contextualizing education on leadership and building relationships to achieve organizational goals.

Partnering With Residents on the Redesign of the Internal Medicine Resident Self-Evaluation Form.

INTRODUCTION: The positive impact of resident-driven synthesis of assessment data has been associated with increased intrinsic motivation to learn and create an individualized strategy to improve performance. The objective of the study was to incorporate residents' recommendations for restructuring the self-assessment metric into a tool that will promote a well-organized and effective self-improvement plan. MATERIALS AND METHODS: Residents and faculty collaborated on pre- and post-intervention questionnaires to assess the barriers to the timely completion of the current self-evaluation form and gather information on the tool's ability to stimulate the formation of concrete goals. The residents were also invited to provide their recommendations on the structure of the new tool and the educational domains that were assessed by the tool. The post-survey also evaluated the capacity of the proposed tool to guide residents in establishing specific goals.  Results: The new form is concise and more precise in assisting the learner in developing short-term and long-term goals and the strategies and resources to achieve them.  Discussion: Collaborating with the learners created an opportunity to address the faculty's and residents' most important concerns about the effectiveness of the metric. CONCLUSION:  In a learner-centered model, resident participation is critical in designing/redesigning a practical self-assessment tool for residents in Internal Medicine.

May-Thurner Syndrome: A Suspicion That Led to an Incidental Discovery.

May-Thurner syndrome (MTS)/Iliac vein compression syndrome is characterized by left iliac vein stenosis secondary to compression by the right common iliac artery against the fifth-lumbar vertebra. It increases the incidence of deep venous thrombosis (DVT). We had a 43-year-old female presenting with left leg swelling and was found to have extensive DVT provoked by a long history of travel. Because of the extension of her thrombus, a catheter-guided thrombectomy (CDT) was planned and findings of MTS were identified incidentally. She had an endovascular stent placed and was discharged on long-term anticoagulation.

Hospital Utilization for Patients With Cirrhosis and Severe Ascites in a Model of Outpatient Paracentesis by Interventional Radiology.

BACKGROUND:  Paracentesis is currently performed by interventional radiologists (IR) rather than gastroenterologists/hepatologists or internists. In this model of care, there is usually no evaluation of patients' renal function or adjustment of their medications at the time of paracentesis. The objectives of this study were to analyze hospital utilization and cirrhosis complications within six months of index outpatient paracentesis by IR and to identify potential areas of improvement in care. METHODS: This is a retrospective study of patients with cirrhosis and ascites who underwent outpatient paracentesis by IR between October 15, 2015, and October 15, 2018, at a tertiary academic medical center. We collected demographics, data on cirrhosis etiology/complications, laboratory tests, provider notes, outpatient paracentesis dates, emergency department (ED) visits, hospitalizations, and ICU admissions within the following six months post index paracentesis. Associations between categorical predictors and clinical outcomes were analyzed using the chi-square test. Associations between quantitative predictors and clinical outcomes were analyzed using the Wilcoxon rank sum test. RESULTS: Our study included 69 unique patients who had at least one outpatient encounter for paracentesis by IR in the study period. Most patients were men (71%), had alcohol-related cirrhosis as primary etiology (53.6%), an average age of 60 years, and an average Model for End-Stage Liver Disease-sodium (MELDNa) score at baseline of 16. Within six months from index paracentesis, 44 patients (64.7%) underwent repeat IR outpatient paracentesis (total 187 paracenteses, 4.25 paracenteses/patient), 43 patients (62.3%) had ER visits (total 118 ER visits, 2.8/patient), 41 patients (59.4%) had hospital admissions (total 88 admissions, 2.2/patient), and 11 patients required ICU admission. Complications of cirrhosis noted during follow-up included hepatic encephalopathy (40.5%), acute kidney injury (38.2%), upper gastrointestinal (UGI) bleeding (16%), and spontaneous bacterial peritonitis (SBP) in 15%. The mortality rate at six months was 20%. On multivariate analysis, the predictive factors for mortality were older age (p = 0.03) and MELDNa score (p = 0.02). Baseline MELDNa was predictive of acute kidney injury (p = 0.02), UGI bleed (p < 0.01), and ICU admission (p < 0.01), but not of SBP, encephalopathy, ED visit, or hospital admissions. Among patients with more than one paracentesis (64%),six patients underwent transjugular portosystemic shunt (TIPS), but there was no documentation of TIPS consideration in 31 patients (70.4%). A total of 20 patients (29%) were waitlisted for liver transplantation. CONCLUSION: In this contemporary cohort of patients with cirrhosis undergoing outpatient IR paracentesis, we found a high rate of short-term cirrhosis complications and hospital utilization, while TIPS consideration was very low. Further data are needed to identify specific gaps in care, but IR paracentesis should be integrated within a multidisciplinary management model, with emphasis on early TIPS in eligible patients, as recommended by the current practice guidelines.

The Great Mimicker: Cutaneous Metastatic Melanoma Presenting as a Non-resolving Pleural Effusion.

Although melanoma starts as a local disease, it can metastasize to other sites of the body including the lung, brain, liver, and intestines. However, pleural involvement is a rare presentation. Here, we present a case of a 57-year-old man with a history of stage IIA cutaneous melanoma, that relapsed 3 years after cutaneous resection, presenting with a non-resolving pleural effusion. Pleural fluid analysis was consistent with an exudative effusion, and pleural biopsy confirmed metastatic melanoma. The patient was treated with dual therapy of ipilimumab and nivolumab, as per National Comprehensive Cancer Network guidelines, with good response. Thus, we recommend having a high index of clinical suspicion for metastatic pleural melanoma when a patient with a history of cutaneous melanoma presents with a non-resolving pleural effusion.

Warfarin-Induced Skin Necrosis Despite Enoxaparin Bridging Therapy.

Skin necrosis is a rare albeit severe complication of warfarin use for anticoagulation, resulting in significant morbidity and mortality. Here, we present the case of a 58-year-old woman who developed erythema and pain in her left leg two weeks after initiation of warfarin therapy with concomitant early administration of heparin for a deep vein thrombosis and pulmonary embolism. Subsequently, the erythema progressed to skin necrosis, and a diagnosis of warfarin-induced skin necrosis (WISN) was suspected. Warfarin was discontinued, and unfractionated heparin was commenced. The simultaneous presence of eosinophilia pointed toward an associated drug-related hypersensitivity reaction. Dexamethasone was added to the medication regimen. The patient was discharged on a factor Xa inhibitor and prednisone. Recognizing WISN is crucial in patients receiving anticoagulation. The diagnosis can be particularly challenging in cases when bridging anticoagulation has been previously completed. Early diagnosis and drug discontinuation are critical to ensuring a favorable prognosis. Steroids may also play a role in the treatment of this condition if an associated drug hypersensitivity is identified.

Trapped in the Bowel.

Intussusception in adults is a rare condition and is usually associated with organic disease. It has been implicated for 1% of all bowel obstructions. Clinical presentation can be non-specific and the rarity of the classic triad of abdominal pain, vomiting, and currant jelly stools contributes to late diagnosis and treatment. A 95-year-old lady presented to the emergency department for evaluation of nausea, vomiting, and a two-month history of intermittent diarrhea, which had been worsening for a few days prior to admission. On examination, the abdomen was soft but tender on deep palpation, with audible bowel sounds. No organomegaly or costovertebral angle (CVA) tenderness was appreciated. CT abdomen revealed a long segment of the colon with a loop within loop appearance from the proximal transverse colon to the distal descending colon, consistent with intussusception. The patient was taken to the operating room where local exploration using laparoscopy revealed complete telescoping and intussusception of terminal ileum into the distended ascending and transverse colon and the patient underwent right hemicolectomy. The signs and symptoms of intussusception among the elderly are very non-specific and include nausea, vomiting, change in bowel habits, and gastrointestinal bleeding. Since the classic triad of symptoms (abdominal pain, vomiting, and currant jelly stools) is rarely observed, timely diagnosis and management become a challenge for clinicians. Literature suggests that up to 90% of adults with intussusception present with ongoing abdominal pain. Especially in outpatient settings, patients presenting with intermittent abdominal pain that resolves quickly with simple analgesia should be promptly evaluated. This case illustrates that the rarity of incidence and non-specific clinical presentation are potential barriers towards timely diagnosis and treatment of intussusception among adults, especially the elderly population. Keeping a low threshold for prompt evaluation using appropriate imaging modalities can help overcome this challenge and help reduce the surgical burden.

Pancoast-Tobias Syndrome: A Unique Presentation of Lung Cancer.

A 65-year-old man with 50 pack-year smoking history presented to the emergency department for evaluation of upper back and right shoulder pain secondary to a fall. Physical examination was notable for anisocoria with a constricted left pupil (miosis), mild ptosis of the left eyelid, and bilateral shoulder pain, right more than left, with both passive and active movements. Chest computed tomography identified a soft tissue mass at the left lung apex with extension into the pleural surface, associated with destructive osseous changes of the right scapula, adjacent ribs, and thoracic vertebral bodies. Imaging of the brain revealed multiple masses suspicious of metastatic brain lesions. Biopsy of the right supraclavicular lymph node revealed lung tissue adenocarcinoma and negative Kirsten rat sarcoma viral oncogene homolog (K-Ras), epidermal growth factor receptor (EGFR), B-raf proto-oncogene (BRAF), C-ros oncogene 1 (ROS1), and anaplastic lymphoma kinase (ALK) rearrangement. Recognizing Pancoast syndrome in patients with significant smoking history, anisocoria, and shoulder pain is crucial for identifying the underlying etiology and expediting the treatment.

Use of Guideline-Directed Medical Therapy in Patients With ST-Elevation Myocardial Infarction.

Introduction ST-elevation myocardial infarction (STEMI) is a serious manifestation of coronary artery disease and remains a significant contributor to morbidity and mortality worldwide. To reduce the risk of recurrent cardiovascular disease (CVD) events, the American College of Cardiology (ACC) and American Heart Association (AHA) recommend the use of five classes of medications after acute coronary syndrome (ACS). The purpose of this study was to evaluate whether STEMI patients admitted to our community hospital were discharged on optimal medical therapy based on the latest AHA/ACC guidelines. Methods A retrospective, single-center electronic medical records review was conducted at our community hospital between July 2017 and December 2018. Patients included in the study were admitted to our hospital through the emergency department as STEMI alerts. We reviewed the discharge prescriptions and assessed compliance with the medication regimen endorsed by AHA/ACC, which includes aspirin, P2Y12 inhibitors, ß-blockers, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and statins. Results A total of 147 patients were included in our study. The mean age of our study population was 62 ± 12.48 years. 97.2% of all patients with STEMI underwent coronary angiography. Hypertension (65.9%) was the most common comorbidity followed by hyperlipidemia (54.42%), diabetes mellitus (29.25%), and history of coronary artery disease (CAD) (24.48%). Among patients with successful reperfusion, 87.4% of the patients received the combination of four guideline-directed medical therapy (GDMT) (comprising dual antiplatelet therapy, a ß-blocker, and a statin) and 57% were discharged on five guideline-directed medical treatment (the combination of dual antiplatelet therapy, a ß-blocker, an ACEIs or an ARB, and a statin). Conclusion Optimal secondary prevention medications are known to be effective in reducing the risk of repeat ischemic events in ACS. This study demonstrated that adherence to GDMT in our community-based hospital study is better compared to prior studies but remained suboptimal. Potential strategies to improve adherence to guidelines are necessary.

Brain Natriuretic Peptide and Troponin T in Patients With Acute Pulmonary Embolism and Grade 3 Obesity: A Retrospective Analysis.

Introduction The interpretation of brain natriuretic peptide (BNP) and Troponin T (TnT) in patients with obesity is very challenging. The applicability of these biomarkers as prognostic indicators of increased mortality in pulmonary embolism (PE) in patients with Grade 3 obesity has yet to be determined. Methods To investigate whether the combination of BNP and TnT may help to identify patients at low risk for short-term mortality, we assessed 92 patients admitted with the diagnosis of PE and Grade 3 obesity. The study endpoint was all-cause mortality at 30 days. Results The negative predictive value (NPV) of these tests combined is 98.8%; however, we were not able to detect a statistically significant difference between the patients who had a BNP < 100 pg/mL and TnT < 0.03 ng/mL and the other individuals who had either BNP ≥ 100 pg/mL or TnT ≥ 0.03 or both. The mortality rate was 5.43% within 30 days of the diagnosis. The logistic regression analysis using BNP and troponin as continuous variables identified BNP (p < 0.005) as an independent predictor for 30 days mortality. Receiver operating characteristic (ROC) analysis determined that a BNP level of 684 pg/mL was the cutoff level to predict mortality in the population studied. Conclusions Our results support that BNP and TnT levels retain an excellent NPV among patients with PE and Grade 3 obesity. BNP testing could be an independent predictor of high-risk patients in this population. The low incidence of all-cause mortality in this study (5.43%) is primarily explained by the more frequent use (9.75%) of systemic or catheter-based thrombolysis associated with a lower rate of major bleeding compared to the general population.

Designing a Curriculum for the Disclosure of Medical Errors: A Requirement for a Positive Patient Safety Culture.

The Accreditation Council for Graduate Medical Education (ACGME) has endorsed the disclosure of adverse treatment events as a common program requirement for resident education and experience since July 2019. This article explores the residents' current attitudes and knowledge in the disclosure of medical errors and the efforts to design a more specific and effective educational program. We conducted a cross-sectional survey of medical residents toward this end. We observed that 62.5% of the residents were not familiar with the error-reporting process at our institution. General concerns about disclosing errors are related primarily to negative patient reactions (66.7%). The majority (58.3%) of the trainees' negative psychological experience after an unanticipated outcome resulting in harm has caused increased anxiety about future errors. To ensure a positive error-disclosure culture, the curriculum must include efforts to educate trainees on the error-reporting system and the disclosure process and should create an opportunity for the organization to establish programs and policies to guide practitioners through the process of disclosures.

Sinus Venosus Atrial Septal Defect: A Challenging Diagnosis.

Sinus venosus atrial septal defect (SVASD) is a rare adult congenital heart disease which permits shunting of blood from the systemic to the pulmonary circulation and is commonly associated with anomalous pulmonary venous return. We report a case of a 27-year-old man with a history of premature birth and unilateral cryptorchidism who was admitted for syncope. Electrocardiogram (ECG) demonstrated atrial fibrillation (AF)and S1Q3T3 pattern along with an incomplete right bundle branch block. Transthoracic echocardiography (TTE) suggested the presence of right ventricular pressure and volume overload and severe right ventricular and right atrial enlargement. The agitated saline study was negative suggesting no inter-atrial communication. Transesophageal echocardiography (TEE) demonstrated a superior SVASD and raised the possibility of an anomalous pulmonary venous connection. Chest computed tomography identified the right superior pulmonary vein connection to the superior vena cava. The diagnosis of SVASD poses multiple challenges from the variety of symptoms to the selection of appropriate imaging and the complexity of surgical treatment.

"D" is for Dilemma.

Immunoglobulin D (IgD) monoclonal gammopathy is a rare subtype of multiple myeloma (MM) associated with a worse prognosis compared with other variants of MM. A 61-year-old man with no known past medical history presented with complaints of abdominal pain, nausea, and vomiting for three weeks. Physical examination revealed mild epigastric tenderness. Laboratory data demonstrated a significantly elevated creatinine with minimal proteinuria and small abnormality in the gamma fraction. Ultrasound of the kidneys described normal-sized kidneys. Serum-free light chains and immunofixation were consistent with IgD kappa monoclonal gammopathy. Kidney biopsy revealed cast nephropathy. Bone marrow biopsy was remarkable for sheets of CD 38+ plasma cells comprising approximately 80% of the marrow cells. Recognizing the atypical presentation of IgD MM is crucial to facilitate early diagnosis and management and improve the prognosis of this subtype of MM.

Post-Cholecystectomy Mirizzi Syndrome: A Case Report and Review of the Literature.

BACKGROUND Mirizzi syndrome is biliary obstruction caused by extrinsic compression of the distal common hepatic duct by a gallstone in the adjacent cystic duct or infundibulum of the gallbladder. Post-cholecystectomy Mirizzi syndrome (PCMS) is Mirizzi syndrome in the post-surgical absence of a gallbladder. This case report of PCMS and review of the literature illustrates the diagnostic and therapeutic challenges in evaluating and managing Mirizzi syndrome. CASE REPORT A 44-year-old female with a remote history of laparoscopic cholecystectomy presented to a community teaching hospital with acute and severe upper abdominal pain and tenderness. Laboratory data revealed markedly elevated transaminases of a magnitude most often observed with hepatitis from acute viral infection, ischemia, or exposure to a hepatotoxin. PCMS was ultimately diagnosed at endoscopic retrograde cholangiopancreatography after being misdiagnosed as choledocholithiasis on magnetic resonance cholangiopancreatography. After transfer to an academic quaternary care referral hospital, the patient's extrahepatic biliary tree was reportedly cleared of gallstones following endoscopically-directed shock-wave lithotripsy performed at repeat -endoscopic retrograde cholangiography. CONCLUSIONS Recognizing post-cholecystectomy syndrome, in general, and PCMS, in particular, is critical when caring for patients presenting with persistent or recurrent symptoms or signs of biliary obstruction following cholecystectomy. Expediently identifying and definitively relieving the biliary obstruction, while limiting the risk of iatrogenic complication, is the priority when caring for patients with PCMS.

A Case of Rheumatoid Arthritis and Paget Disease of Bone.

BACKGROUND Paget disease is a primary bone disease with adjacent joint involvement that commonly presents with degenerative arthritis. Rheumatoid arthritis (RA) is mainly an articular disease with symmetric synovitis of the peripheral joints and usually does not involve the lumbar spine. The coexistence of Rheumatoid Arthritis and Paget disease of bone is infrequently reported in the literature. CASE REPORT A 74-year-old African-American man was referred for the investigation of symmetrical polyarthritis, left upper arm joint deformity, and low back pain. X-ray imaging of the hands demonstrated bilateral erosions and deformities of the carpal bones, and the left arm showed mixed lytic and sclerotic bone lesions. Laboratory tests showed high levels of rheumatoid factor and alkaline phosphatase. Analysis of the synovial fluid from the left knee was consistent with inflammatory joint disease. CONCLUSIONS The purpose of this article is to present the diagnostic challenges associated with the rare coexistence of Rheumatoid Arthritis and Paget disease of bone in the same patient. The correct diagnosis of both diseases has important consequences in preventing treatment delay.