Learning style preferences of internal medicine residents and in-training examination scores: is there a correlation?

The internal medicine in-training examination (IM-ITE) has been traditionally used as a measuring tool to evaluate the base of knowledge of the residents in internal medicine residency programs across the US. Multiple interventions has been applied and studied to increase the first-time passing rate of ABIM, as it is an indicator of each residency program's performance and ranking. Additionally, studies have demonstrated that different learning styles and preferences are a predictor of exam results; however, it is not well known whether certain preferred learning styles are correlated with certain IM-ITE results. Primary objective of our study was to find a correlation between residents' preferred learning style, based on Kolb learning style inventory, and their PGY1 and PGY2 IM-ITE performance score difference. Secondary objective was to find the correlation between PGY2s' IM-ITE score and their preferred learning styles based on the Kolb learning style inventory. Mean scores of PGY1 and PGY2 IM-ITE were compared in each learning style group. Additionally, the mean difference between the PGY1 and PGY2 IM-ITE scores for each learning group was compared as well. The analysis of the mean IM-ITE score from PGY1 to PGY2 between groups revealed a statistically significant improvement in IM-ITE score from PGY1 to PGY2 in all groups, however, with a larger difference in one of the groups.

Adult onset Still's disease in the elderly: a case-based literature review.

BACKGROUND: Adult onset Still's disease (AOSD) is a rare inflammatory disorder that classically presents with high spiking fevers, evanescent rash, and arthritis. The diagnosis is one of exclusion and can be further complicated by atypical presentations, particularly in elderly patients in whom AOSD is very rare. CASE PRESENTATION: A case of AOSD in a 73-year-old woman with a non-classic presentation, leading to delayed diagnosis and management, is presented along with a review of the English literature for AOSD cases in elderly people over 70 years of age. Thirty nine case reports and series were identified and the current case was added, totaling 42 individual cases. Significant findings included a four-times higher prevalence in females, a higher prevalence of macrophage activation syndrome despite lower mortality, the presence of pruritic rash in almost one fifth of the cases, and high prevalence of delayed diagnosis. CONCLUSIONS: AOSD in the elderly may vary from the classic criteria described in the medical literature and may lead to delayed diagnosis and management. Further evaluation and better characterization of AOSD in the elderly remains an area of interest.

ANCA-negative microscopic polyangiitis with diffuse alveolar hemorrhage masquerading as congestive heart failure.

BACKGROUND: Microscopic polyangiitis (MPA) is a subtype of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), involving small and medium sized vessels, often affecting the kidneys and lungs. Anti-neutrophil cytoplasmic antibody (ANCA) is detected in up to 90% of cases of MPA and its detection helps guide diagnosis, however cases of ANCA-negative MPA have been reported, hence definitive diagnosis relies on tissue biopsy. CASE REPORT: A 23-year-old man was evaluated for dyspnea and pleuritic chest pain, and found to have bilateral intra-alveolar opacities and hilar adenopathy. Diagnostic work up revealed positive anti-nuclear antibodies (ANA) and negative ANCA, which in the setting of a non-classical presentation, delayed diagnosis and appropriate treatment. Due to persistent symptoms and a high suspicion for autoimmune disease with pulmonary-renal syndrome, he underwent lung biopsy which revealed intra-alveolar hemorrhage and capillaritis indicative of microscopic polyangiitis (MPA). Surprisingly, kidney biopsy was not typical of classic MPA, but revealed less common features. Due to therapeutic noncompliance he was readmitted multiple times thereafter with rare complications of MPA such as acute pancreatitis and hemorrhagic pericardial effusion with tamponade. CONCLUSION: This case serves as an important clinical reminder to consider AAV even in those with negative ANCA serologies and a high suspicion for pulmonary-renal syndrome. It also demonstrates the high morbidity in cases of diagnostic delay and inadequate treatment.

Immune checkpoint inhibitor-induced inflammatory arthritis: identification and management.

INTRODUCTION: Immune checkpoint inhibitors (ICIs) have proved to be groundbreaking in the field of oncology. However, immune system overactivation from ICIs has introduced a novel medical entity known as immune-related adverse events (irAEs), that can affect any organ or tissue. ICI-induced inflammatory arthritis (ICI-IIA) is the most common musculoskeletal irAE and can lead to significant morbidity and limitation in anti-cancer therapy. AREAS COVERED: In this review, the authors focus on ICI-IIA. Relevant articles were identified through PubMed searches, spanning 2010 to the present. The authors detail the current understanding of its pathogenesis, diagnostic evaluation, and management strategies. EXPERT OPINION: ICI-IIA is a complex irAE that we are just beginning to understand mechanistically and pathologically. It often presents later in the disease course than other irAEs and, due to various reasons, is under-recognized. In some patients, ICI-IIA may become a chronic disease, which distinguishes it from most irAEs that resolve after ICI discontinuation. Multiple important questions still demand further research including which patients may develop ICI-IIA? What are possible diagnostic and prognostic markers? Do anti-arthritis therapies interfere with the anti-tumor response? and when should steroid-sparing agents be initiated? Close collaboration and shared decision-making between oncologists, rheumatologists, and the patient are essential when managing this particular irAE.

A tale of autoimmunity: thymoma, thymectomy, and systemic lupus erythematosus.

The thymus plays an integral role in immune system regulation, modulating the development, diversity, and selection of T lymphocytes, a critical feature for the prevention of T cell-mediated autoimmunity. Thymoma is a rare tumor of the thymus. Autoimmune diseases and paraneoplastic syndromes such as myasthenia gravis, pure red blood cell aplasia, and systemic lupus erythematosus, although relatively uncommon, have been described in association with thymomas. Rare cases of post-thymectomy autoimmune related diseases, including systemic lupus erythematosus and pure red cell aplasia, have been reported in the literature. Here, we present the case of a 65-year-old male who developed systemic lupus erythematosus 2 years after thymectomy in the setting of thymoma-associated pure red cell aplasia.

Sweet's Syndrome: A Classical Presentation of a Rare Disease.

Sweet's syndrome, also known as acute febrile neutrophilic dermatosis, is a rare disorder that typically presents with rapid appearance of tender skin lesions accompanied by fever and leukocytosis with neutrophilia. Its pathogenesis is not fully understood. The syndrome is generally classified into classical, malignancy-associated, and drug-induced categories, each of which has its specific characteristics. In this article, we present a case of classical Sweet's syndrome in a woman who presented with an acute viral illness.

Major Stressful Life Events and Risk of Developing Lung Cancer: A Case-Control Study.

BACKGROUND: Lung cancer is the leading cause of cancer-related mortality and is strongly linked with smoking. We sought to determine whether major stressful life events (e.g. divorce) are also a risk factor for developing lung cancers. METHODS: We performed a matched case-control study. Cases (CA) were lung cancer patients diagnosed within the previous 12 months. Controls (CO) were patients without a prior history of malignancy. Data on major stressful life events were collected using the modified Holmes-Rahe stress scale. The primary endpoint was the odds of having a major stressful life event between CA and CO. A sample of 360 patients (CA = 120, CO = 240) was needed to achieve 80% power to detect an odds ratio (OR) of 2.00 versus the alternative of equal odds using χ 2 = 0.05. RESULTS: Between May 2015 and December 2016, we enrolled 301 patients (CA = 102, CO = 199), matched for median age (CA = 64.4 years, CO = 63.9 years), sex (CA-Male = 48%, CO-Male = 49.2%), and smoking status (ever smoker, CA = 84%, CO = 85%). There was no difference in lifetime stressful life event rate between CA and CO (95% vs 93.9%; P = .68). However, CA were significantly more likely to have had a stressful event within the preceding 5 years than CO (CA = 77.4% vs CO = 65.8%; P = .03, OR = 1.78). ß-blocker use was significantly higher among CO (CA = 29.4%, CO = 49.7%; P = .0007, OR = 0.42), suggesting a protective effect. CONCLUSION: Patients with lung cancer are significantly more likely to have had a major stressful life event within the preceding 5 years. In addition, use of ß-blockers may be protective against lung cancer.

A 5-Fr Externalized Nephroureteral Catheter as the Sole Protective Device for Pediatric Pyeloplasty: The Experiences of 142 Patients.

BACKGROUND: Pyeloplasty for ureteropelvic junction obstruction correction is a common procedure, but the optimal method for protective diversion after pyeloplasty is still a matter of debate. OBJECTIVES: Here, we present our clinical trial experience using a single percutaneous externalized nephroureteral (NU) 5-Fr catheter (infant feeding tube) with multiple side holes as the sole instrument of drainage to provide a protective mechanism. MATERIALS AND METHODS: In this prospective study, we analyzed the charts of 142 patients who underwent pyeloplasty from August 2001 through October 2008. We used a single externalized NU 5-Fr catheter with multiple side holes for postoperative upper tract diversion. The catheter was removed in the office after 10 - 14 days. Complications from the use of this catheter, including poor catheter function, premature dislodgement, urinary tract infection, leakage, urinoma, and anastomotic stenosis, were evaluated. The operations were performed by two surgeons at two separate centers. RESULTS: In all, 148 pyeloplasty procedures were performed on 142 patients. The mean hospital stay length was 2 (1 - 3) days. A contrast study through a catheter demonstrated excellent drainage with no leakage in all patients. Immediately after catheter removal, febrile urinary tract infection and transient obstructive symptoms and signs occurred in 15 patients. CONCLUSIONS: Using a percutaneous externalized NU 5-Fr catheter was sufficient as a protective measure after open pyeloplasty. It costs less than other diverting systems, such as DJ, and can be removed in the office. Therefore, it can be a safe and cost effective procedure, especially in developing countries where cystoscopic set ups are not readily available. There were only a few notable complications.

Preserving the continuity of round ligament along with hernia sac in indirect inguinal hernia repair in female children does not increase the recurrence rate of hernia. Experience with 217 cases.

PURPOSE: In the standard classical method of indirect inguinal hernia (IIH) repair in female children, after transligation of hernia sac along with round ligament at the level of internal ring, the distal portion is divided or cut off, thereby removing a possible future support for the internal genital organs. In this article, we propose a modification to the standard technique for IIH repair which preserves the continuity of round ligament along with hernia sac without increasing the recurrence rate. METHODS: In a 3-year prospective clinical trial, from March 2007 to March 2010, IIH repairs were performed on 217 female children. In all of these cases, the hernia sac along with round ligament is only transligated at the level of internal ring and a window is created in the distal portion of the sac to prevent a hydrocele formation and the continuity of round ligament along with hernia sac was preserved. The charts of these patients were then analyzed to determine if recurrence had occurred. In addition, we noted any other early postoperative complications such as wound infection, bleeding, and tolerance. RESULTS: Within the 25-month mean follow-up period (6-36 months), none of the patients developed any of the above-mentioned complications. The most important result of this study was that preserving the continuity of round ligament along with hernia sac did not increase the rate of recurrence. CONCLUSION: On the basis of results obtained from this study, we conclude that preserving the continuity of round ligament along with hernia sac in female children during IIH repair does not increase the rate of recurrence, and is less intrusive to the normal anatomy of the inguinal region and needs less time to do.