Infective endocarditis initially manifesting as pseudogout.

Infective endocarditis is a commonly encountered disease in which diagnosis is often challenging due to the variety of clinical manifestations. Early identification is key due to risk of mortality without treatment. In this case, a 31-year-old man presented with pseudogout of the right ankle and COVID-19 infection. Further workup showed blood cultures growing Staphylococcus aureus, and the diagnosis of infective endocarditis was confirmed by echocardiography. Independently, pseudogout and infective endocarditis result in activation of the innate immune system and can manifest with joint inflammation. Their co-occurrence likely resulted in an augmented inflammatory response due to overlap in their pathophysiologic pathways.

Medical Student Attitudes toward USMLE Step 1 and Health Systems Science - A Multi-Institutional Survey.

Phenomenon: Because of its importance in residency selection, the United States Medical Licensing Examination Step 1 occupies a critical position in medical education, stimulating national debate about appropriate score use, equitable selection criteria, and the goals of undergraduate medical education. Yet, student perspectives on these issues and their implications for engagement with health systems science-related curricular content are relatively underexplored. Approach: We conducted an online survey of medical students at 19 American allopathic medical schools from March-July, 2019. Survey items were designed to elicit student opinions on the Step 1 examination and the impact of the examination on their engagement with new, non-test curricular content related to health systems science. Findings: A total of 2856 students participated in the survey, representing 23.5% of those invited. While 87% of students agreed that doing well on the Step 1 exam was their top priority, 56% disagreed that studying for Step 1 had a positive impact on engagement in the medical school curriculum. Eighty-two percent of students disagreed that Step 1 scores should be the top item residency programs use to offer interviews. When asked whether Step 1 results should be reported pass/fail with no numeric score, 55% of students agreed, while 33% disagreed. The majority of medical students agreed that health systems science topics were important but disagreed that studying for Step 1 helped learn this content. Students reported being more motivated to study a topic if it was on the exam, part of a course grade, prioritized by residency program directors, or if it would make them a better physician in the future. Insights: These results confirm the primacy of the United States Medical Licensing Examination Step 1 exam in preclinical medical education and demonstrate the need to balance the objectives of medical licensure and residency selection with the goals of the broader medical profession. The survey responses suggest several potential solutions to increase student engagement in health systems science curricula which may be especially important after Step 1 examination results are reported as pass/fail.

The Growth of Hospitalists and the Future of the Society of General Internal Medicine: Results from the 2014 Membership Survey.

According to the most recent annual membership surveys, hospitalists are a rapidly growing component of the Society of General Internal Medicine (SGIM). Should this trend continue, hospitalists could increase from 22% of SGIM membership in 2014 to nearly 33% by 2020. Only 34% of hospitalists who responded to the survey, however, consider SGIM their academic home, compared to 54% of non-hospitalist respondents. Based on these survey findings, it is clear that the landscape of general internal medicine is changing with the growth of hospitalists, and SGIM will need to strategize to keep these hospitalist members actively engaged in the organization.

Milestones for Internal Medicine Sub-interns.

BACKGROUND: As residency programs move toward measuring milestones for competency-based education assessment, medical schools will need to collaborate with residencies to determine competencies for graduating students. The objective of this study is to define the educational milestones for fourth-year medical students during an Internal Medicine sub-internship. METHODS: A cross-sectional Internet-based survey (with attention to validity evidence) was developed in early 2013 and administered to Internal Medicine attendings and Internal Medicine sub-interns working on an inpatient team at 3 academic medical centers. With the purpose to determine the milestones for sub-interns, items asked respondents what responsibilities a sub-intern could be entrusted to perform without direct supervision. RESULTS: Faculty responded that behaviors sub-interns could perform with indirect supervision were mostly at the "reporter" level, including completing a history and physical examination and collecting data such as test results. Other skills such as venipuncture and some communication skills such as calling consults, providing patient counseling, responding to pages, and creating discharge instructions were examples of tasks in which the majority of faculty felt that students were progressing toward unsupervised practice. Behaviors where the majority of faculty would always supervise a medical student performance included performance on the "interpreter" level, including interpreting electrocardiograms, significant physical examination findings, and laboratory results. Medical students less commonly noted needing supervision on the majority of the items when compared with faculty. CONCLUSION: Tasks in the reporter domain such as taking a history, collecting medical records, and reporting results can be characterized as medical student milestones.

Formerly obese, now thin and confused: the utility of mnemonics in the approach to altered mental status.

Altered mental status represents a common cause for admission to general medicine services. Often a significant workup ensues to define an underlying etiology. When a history of bariatric surgery with small bowel resection precedes the presentation, the differential diagnosis expands. We review a patient, having prior bariatric surgery and small bowel resection, who presents with altered mental status. After an extensive workup, she was diagnosed with a rare clinical problem, D-lactic acidosis. In presenting this case, we examine the use of mnemonics in medicine and how this can assist in solving clinical problems.

Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis.

Nearly half of medical errors can be attributed to an error of clinical reasoning or decision making. It is estimated that the correct diagnosis is missed or delayed in between 5% and 14% of acute hospital admissions. Through understanding why and how physicians make these errors, it is hoped that strategies can be developed to decrease the number of these errors. In the present case, a patient presented with dyspnea, gastrointestinal symptoms and weight loss; the diagnosis was initially missed when the treating physicians took mental short cuts and used heuristics as in this case. Heuristics have an inherent bias that can lead to faulty reasoning or conclusions, especially in complex or difficult cases. Affective bias, which is the overinvolvement of emotion in clinical decision making, limited the available information for diagnosis because of the hesitancy to acquire a full history and perform a complete physical examination in this patient. Zebra retreat, another type of bias, is when a rare diagnosis figures prominently on the differential diagnosis but the physician retreats for various reasons. Zebra retreat also factored in the delayed diagnosis. Through the description of these clinical reasoning errors in an actual case, it is hoped that future errors can be prevented or inspiration for additional research in this area will develop.

Genetic clamping of renin gene expression induces hypertension and elevation of intrarenal Ang II levels of graded severity in Cyp1a1-Ren2 transgenic rats.

INTRODUCTION: Transgenic rats with inducible angiotensin II (Ang II)-dependent hypertension (strain name: TGR[Cyp1a1-Ren2]) were generated by inserting the mouse Ren2 renin gene, fused to the cytochrome P450 1a1 (Cyp1a1) promoter, into the genome of the rat. The present study was performed to characterise the changes in plasma and kidney tissue Ang II levels and in renal haemodynamic function in Cyp1a1-Ren2 rats following induction of either slowly developing or malignant hypertension in these transgenic rats. MATERIALS AND METHODS: Arterial blood pressure (BP) and renal haemodynamics and excretory function were measured in pentobarbital sodium-anaesthetised Cyp1a1- Ren2 rats fed a normal diet containing either a low dose (0.15%, w/w for 1415 days) or high dose (0.3%, w/w for 1112 days) of the aryl hydrocarbon indole-3-carbinol (I3C) to induce slowly developing and malignant hypertension, respectively. In parallel experiments, arterial blood samples and kidneys were harvested for measurement of Ang II levels by radioimmunoassay. RESULTS: Dietary I3C increased plasma renin activity (PRA), plasma Ang II levels, and arterial BP in a dose-dependent manner. Induction of different fixed levels of renin gene expression and PRA produced hypertensive phenotypes of varying severity with rats developing either mild or malignant forms of hypertensive disease. Administration of I3C, at a dose of 0.15% (w/w), induced a slowly developing form of hypertension whereas administration of a higher dose (0.3%) induced a more rapidly developing hypertension and the clinical manifestations of malignant hypertension including severe weight loss. Both hypertensive phenotypes were characterised by reduced renal plasma flow, increased filtration fraction, elevated PRA, and increased plasma and intrarenal Ang II levels. These I3C-induced changes in renal haemodynamics, PRA and kidney Ang II levels were more pronounced in Cyp1a1-Ren2 rats with malignant hypertension. Chronic administration of the AT1-receptor antagonist, hypertension, the associated changes in renal haemodynamics, and the augmentation of intrarenal Ang II levels. CONCLUSIONS: Activation of AT1-receptors by Ang II generated as a consequence of induction of the Cyp1a1-Ren2 transgene mediates the increased arterial pressure and the associated reduction of renal haemodynamics and enhancement of intrarenal Ang II levels in hypertensive Cyp1a1-Ren2 transgenic rats.