Cytomegalovirus hepatitis and pancreatitis in the immunocompetent.

BACKGROUND: Cytomegalovirus (CMV) is a double-stranded DNA virus and a member of the Herpesviridae family. It is a lytic virus that causes a cytopathic effect in vitro and in vivo. CMV affects nearly all humans, with a 60%-100% seroprevalence worldwide, and in the immunocompetent it typically manifests as a mild and self-limiting mononucleosis syndrome. In immunocompromised patients, CMV has the ability to cause significant inflammation in many different organ systems. CASE REPORT: We report an unusual case of hepatitis and pancreatitis secondary to CMV in an immunocompetent patient. A 29-year-old male was admitted with elevated lipase, elevated aminotransferases, and epigastric pain after an acute viral prodrome. An initial CMV DNA polymerase chain reaction workup was positive, indicating acute or reactivated infection. Liver histology was consistent with CMV infection. Magnetic resonance cholangiopancreatography, endoscopic ultrasound, and intraoperative cholangiogram were not indicative of other etiologies. CMV viremia was successfully cleared with ganciclovir, and the patient experienced clinical and biochemical improvements. CONCLUSION: Pancreatitis and hepatitis secondary to CMV are rare but should be considered in the workup of immunocompetent patients, especially in the presence of a recent viral-like illness.

Should we Google it? Resource use by internal medicine residents for point-of-care clinical decision making.

PURPOSE: To determine which resources residents use at the point-of-care (POC) for decision making, the drivers for selection of these resources, and how residents use Google/Google Scholar to answer clinical questions at the POC. METHOD: In January 2012, 299 residents from three internal medicine residencies were sent an electronic survey regarding resources used for POC decision making. Resource use frequency and factors influencing choice were determined using descriptive statistics. Binary logistic regression analysis was performed to determine relationships between the independent variables. RESULTS: A total of 167 residents (56%) responded; similar numbers responded at each level of training. Residents most frequently reported using UpToDate and Google at the POC at least daily (85% and 63%, respectively), with speed and trust in the quality of information being the primary drivers of selection. Google, used by 68% of residents, was used primarily to locate Web sites and general information about diseases, whereas Google Scholar, used by 30% of residents, tended to be used for treatment and management decisions or locating a journal article. CONCLUSIONS: The findings suggest that internal medicine residents use UpToDate most frequently, followed by consultation with faculty and the search engines Google and Google Scholar; speed, trust, and portability are the biggest drivers for resource selection; and time and information overload appear to be the biggest barriers to resources such as Ovid MEDLINE. Residents frequently used Google and may benefit from further training in information management skills.

Feasibility and acceptability of a structured curriculum in teaching procedural and basic diagnostic ultrasound skills to internal medicine residents.

BACKGROUND: Point-of-care ultrasound has emerged as a powerful diagnostic tool and is also being increasingly used by clinicians to guide procedures. Many current and future internists desire training, yet no formal, multiple-application, program-wide teaching interventions have been described. INTERVENTION: We describe a structured 30-hour ultrasound training course in diagnostic and procedural ultrasound implemented during intern orientation. Internal medicine interns learned basic ultrasound physics and machine skills; focused cardiac, great vessel, pulmonary, and abdominal ultrasound diagnostic examinations; and procedural applications. RESULTS: In postcourse testing, learners demonstrated the ability to acquire images, had significantly increased knowledge scores (P < .001), and demonstrated good performance on practical scenarios designed to test abilities in image acquisition, interpretation, and incorporation into medical decision making. In the postcourse survey, learners strongly agreed (4.6 of 5.0) that ultrasound skills would be valuable during residency and in their careers. CONCLUSIONS: A structured ultrasound course can increase knowledge and can result in learners who have skills in image acquisition, interpretation, and integration in management. Future work will focus on refining and improving these skills to allow these learners to be entrusted with the use of ultrasound independently for patient care decisions.

Point-of-Care Ultrasound in Internal Medicine: A National Survey of Educational Leadership.

BACKGROUND: Ultrasound is a valuable tool in the safe performance of an increasing number of procedures. It has additionally emerged as a powerful instrument for point-of-care assessment by offering internists an opportunity to extend their traditional physical examination. OBJECTIVE: This study explored how internal medicine (IM) educators perceive the use of ultrasound for procedures and point-of-care assessments, the extent to which curricula for teaching IM residents ultrasound skills exist, and perceived barriers to teaching its use. METHODS: In February 2012, we administered a 27-question survey to all members of the Association of Program Directors in Internal Medicine, eliciting their opinions about the use of point-of-care ultrasound. RESULTS: Of 2200 surveys distributed electronically, 234 were returned (a 11% response rate), including 167 by program directors or assistant program directors. Respondents highly rated the usefulness of ultrasound for central-line placement, thoracentesis, paracentesis, and diagnosis of pleural effusions. Evaluation of vena cava and heart, and placement of radial artery catheters received somewhat lower usefulness scores. Forty-five respondents (25%) reported having formal curricula to teach point-of-care ultrasound, and 46 respondents without current ultrasound programs were planning to initiate them in the next 12 months. Potential barriers to teaching and use of ultrasound included the time and cost to train faculty, the cost of ultrasound machines, and the time required to train residents. CONCLUSIONS: Educational leaders in IM view point-of-care ultrasound as a valuable tool in diagnosis and procedures, and many residency programs are teaching these skills to their learners.

Haematological, neurological and electrocardiographic findings in secondary hypothermia.

The association between secondary hypothermia and pancytopaenia is uncommon. A young woman presented with chronic hypothermia (28.8-34.6°C) secondary to surgical hypothalamic injury postcraniopharyingioma resection as a child. Associated findings included pancytopaenia (haemoglobin 8.1 g/dl, leucocytes 3500/mm(3), platelets 63,000/mm(3)), ataxia, upper motor neuron signs, decreased level of consciousness and new ECG changes. An extensive evaluation failed to reveal any cause of pancytopaenia other than chronic hypothermia. The haematological and neurological changes improved after active rewarming.

Efficacy of peer-assisted learning across residencies for procedural training in dermatology.

BACKGROUND: With new care models such as the medical home, there is an expanding need for primary care providers to be trained in dermatologic procedures. Yet, many internal medicine residency program graduates feel unprepared to perform these procedures. The aim of this study was to evaluate the effect of a structured peer-assisted learning approach to improve residents' knowledge and skills related to common dermatologic assessment techniques. METHODS: Eight medicine-dermatology resident educators, with a faculty member, facilitated dermatologic procedure workshops for 28 internal medicine and medicine-pediatrics resident learners. Learners completed preworkshop and postworkshop surveys, assessing their knowledge and skill levels as well as the efficacy of the resident educators and the educational value of the workshop as a whole. RESULTS: All learners were able to properly demonstrate the techniques at the workshop's conclusion. The median sum score of self-reported knowledge increased from 3 to 9.5 (scale, 0-10; P < .001). The median sum score of self-reported skills increased from 10 to 16 (scale, 4-20; P < .001). Resident educators were favorably evaluated by their peers, and 96% of participants rated the experience as being of high educational value. CONCLUSION: Peer-assisted learning is effective in teaching dermatologic procedures in graduate medical education. Resident learners found peer-assisted learning to be beneficial and rated their peer teachers highly. Further studies should focus on outcomes in practice, looking at the number of dermatologic procedures performed by learners, as well as the effects on resident educators.

Impact of new duty-hour rules on residency training.

On the surface, changing the rules related to the number of hours residents work per day and per week sounds like a good idea. Theoretically, residents who work fewer hours would be less tired and provide better patient care. But even small changes in residency training programs have implications for the quality of the educational experience and the cost of training, as well as patient care. This article highlights the challenges that two Minnesota residency programs are facing as they adapt to the new rules around residents' work hours.